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

The patient is a male diagnosed with idiopathic short stature (ISS). This request is for Humatrope. He was diagnosed with delayed puberty and has had a 3-month course of testosterone. His growth hormone (GH) stimulation test in 2018 with arginine and clonidine peaked at 11.6. His GH stimulation test in 2014 with arginine and clonidine peaked at 17.8. 

The health plan's determination is overturned. 

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

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 IGFBP3 or GH stimulation testing with a peak GH less than 10 nanograms/milliliter (ng/ml).The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9). Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient has a pretreatment height less than or equal to -2.25 SD. The height velocity was poor and would not allow the patient to reach a normal adult height. The patient therefore met idiopathic short stature criteria.

The request is consistent with nationally accepted criteria for use of growth hormone. The request is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance Abuse Services

The insurer denied the Inpatient Substance Abuse Services. The denial was reversed. 

This is a male patient who was admitted for inpatient substance detoxification treatment.  At the time of his admission he was experiencing symptoms that included tremors, sweats, irritability, anxiety, and sleeping problems.  He had a Clinical Opiate Withdrawal Scale (COWS) score of 13 and Clinical Institute Withdrawal Assessment score (CIWA) of 10. It was reported that the patient had a more than decade long history of heroin, cocaine, and cannabis use; with 3 previous drug overdoses.  He has had several past inpatient substance detoxification and rehabilitation treatments with unsuccessful results. His medical history includes an immune disorder and liver disease. During his admission he was treated with Methadone and later discharged to a substance residential treatment facility. 

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  Also, according to the LOCADTR he did require 24 hour treatment as he needed detoxification medication to modify withdrawal including taking Methadone.  The patient also had a long history of heavy IV heroin use putting him at high risk for overdose.  He needed 24 hour treatment due to the risk of severe withdrawal.  He continued to use heroin, cocaine, and cannabis so outpatient treatment for detoxification was not considered enough or safe as he needed 24 hour medical detoxification in this hospital then.  The patient was using large amounts of multiple serious substances putting him at risk for severe withdrawal and was a high risk of another accidental overdose and he had 3 already so he required 24 hour medical detoxification treatment in this hospital.  He continued to use substances despite negative consequences including legal problems due to drug possession.  The patient also had family conflicts and serious medical issues due to substance use.  It was not likely that he could attend an outpatient substance detoxification treatment due to his continued use and multiple relapses as well as the medical risks of overdose if continuing to use and the risk of severe withdrawal.  He also required this 24 hour hospital treatment for detoxification prior to going to a 24 hour inpatient rehabilitation substance treatment. 

Based on the above, the medical necessity for the inpatient substance abuse services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of hypertension. He presented to the emergency department complaining of ten days of intermittent chest pain and dyspnea that was worse with exertion and bending over. His blood pressure was 146/90 millimeters of mercury (mmHg) with a heart rate of 99 beats/minute. His physical exam was unremarkable. His electrocardiogram and serum troponin level were normal. Coronary computed tomography (CT) angiography was performed and showed a 70-80% obstruction in the left anterior descending coronary artery and nonobstructive disease elsewhere. He was then admitted to the hospital for cardiac catheterization. This showed no obstructive disease; fractional flow reserve in the left anterior descending and diagonal arteries was normal. He was discharged home.

The health plan's determination is upheld.

This patient presented with atypical chest pain. He was hemodynamically stable. While coronary CT angiography suggested obstructive disease in the left anterior descending coronary artery, his electrocardiogram and cardiac biomarkers were normal. He did not require intensive monitoring or intravenous titration of cardioactive medications. There is no indication in the records provided that other potentially serious diagnoses were considered likely. Thus, per the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes, an inpatient level of care was not medically necessary. The patient could have been managed at a lower level of care in this case.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented for replacement of multiple missing teeth by means of multiple dental implants. The patient also has diabetes mellitus. The issue for review is the medical necessity of the dental implants. The health plan's determination is upheld.
There is literature to support that a complete dentition for oral function is not necessary and questions the need to replace missing molars. In addition, this patient has diabetes mellitus which is associated with delayed wound healing and impaired response to infection. Patients with poorly controlled diabetes suffer from impaired osseointegration, elevated risk of peri-implantitis, and higher level of implant failure making implant replacement not an ideal choice for tooth replacement.
Appeal type: Medical necessity
Decision: Overturned

This case describes a male patient with a complaint of left shoulder pain which began after a slip and fall on some ice. The records show that the patient attempted a cortisone injection done by his primary care physician as well as acupuncture and oral anti-inflammatory medications which failed to relieve his pain in the left shoulder. A magnetic resonance imaging (MRI) scan was obtained of the left shoulder which documented a large U-shaped full thickness tear of the supraspinatus and infraspinatus tendons of the rotator cuff. Based on the patient's persistent symptoms of pain in light of failed conservative treatment, the orthopedic provider has recommended left shoulder arthroscopic surgery for rotator cuff repair. The health plan's determination is overturned.

The requested shoulder surgery in this case is medically necessary for this patient.

The rationale for this determination is based on the provided medical records which document an acute left shoulder injury after a slip and fall. The records also document subsequent attempts at conservative treatment including a cortisone injection, acupuncture and oral anti-inflammatory medications. An MRI scan of the left shoulder done  confirmed a full thickness rotator cuff tear. The proposed arthroscopic rotator cuff repair surgery is medically necessary based on the pre-operative MRI scan findings as well as the patient's motion loss, loss of strength and functional limitations. The proposed surgery is also supported by the current, peer-reviewed orthopedic literature on the topic of rotator cuff repairs as published by Gilotra and colleagues and by Burkhart and associates.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of polio, hypertension, left hip replacement, chronic back pain, and alcohol abuse, who presented to the emergency room (ER) with 2 weeks of left chest pressure and dizziness with exertion. The pain worsened the morning of admission, radiating to the right chest, 10 out of 10 in severity.
The patient was admitted to rule out acute coronary syndrome. The health plan's determination is upheld. The patient was hemodynamically stable, presented with atypical chest pain, had no ischemic changes on EKG, was ruled out for a PE, and had negative cardiac biomarkers.
The patient's HEART score was either 2-3 (depending on if the clinically history is deemed slightly suspicious or moderately suspicious). This places the patient in the low risk category. The patient's thrombolysis in myocardial infarction (TIMI) risk score was either 1 or 2.

The patient was at low risk for ACS.  He did not have STEMI.  He did not have elevated cardiac troponins. TIMI risk score indicated low risk for subsequent cardiac mortality in 30 days.  The patient did not have a TIMI risk score of greater than or equal to 3, and would not have required systemic anticoagulation.
Appeal type: Medical necessity
Decision: Upheld

The patient had presented to the emergency department for evaluation of unsteady gait, intermittent slurred speech, and right facial droop.  The blood pressure was elevated.  The physical examination was significant for dysmetria on finger to nose testing and positive Romberg's sign.  The computed tomography (CT) of the head was negative for acute intracranial process.  Review of laboratory data was significant for mild normocytic anemia.  The health plan's determination of medical necessity is upheld in whole.  The inpatient stay was not medically necessary.  Documentation does not meet medical necessity for inpatient level of care in the management of transient ischemic attack.  The patient could have been adequately managed at a lower level of care.
There was rapid resolution of the patient's neurological symptoms.  The CT of the head was negative for acute infarct or hemorrhage.  There was no documentation of large vessel occlusion, hemodynamically significant carotid artery stenosis, intracardiac thrombus, intravenous thrombolytic therapy, or requirement for blood pressure control with intravenous medication.
Appeal type: Medical necessity
Decision: Upheld

This is a pregnant patient with vaginal spotting. She was sent to the emergency room  for a possible ectopic pregnancy. In the emergency room , an ultrasound confirmed a right adnexal ectopic pregnancy. Vitals signs were stable. She had a laparoscopic right salpingectomy and lysis of adhesions for resolution of the ectopic pregnancy. There was an intraoperative consultation for a possible bowel injury. Radiological exams after surgery showed no bowel injury and she was discharged. The health plan's determination is upheld.

The patient had an ectopic pregnancy, however, there was no active, acute hemorrhage with severe anemia. Vital signs were stable without any shock or cardiovascular compromise. There was no respiratory distress. The surgery was laparoscopic and usually an ambulatory surgery requiring only monitoring after surgery before discharge. Although a bowel perforation was evaluated, no perforation was found and the patient could have been discharged after extended, outpatient monitoring. She had no extensive blood loss, transfusion nor postoperative complication such as acute infection. She had no abnormal vital signs after surgery nor any uncontrolled pain. She progressed well after surgery and was discharged.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.    

This patient is an elderly male who presented for an elective cardiac catheterization in late 2018. The procedure was done for chest pain, shortness of breath, and aortic stenosis. He has past medical history of coronary artery disease, hypertension, hyperlipidemia, sick sinus syndrome, pacemaker placement, Chronic Obstructive Pulmonary Disease (COPD), paroxysmal atrial fibrillation, and non-rheumatic aortic valve stenosis. He underwent the heart catheterization and received angioplasty and coronary stenting to the circumflex artery. He was also shown to have moderate aortic stenosis. There were no procedural complications. He was admitted overnight and discharged home after an uneventful overnight stay. 

Inpatient admission status was not medically necessary for this patient. Per Milliman Care Guidelines (MCG) Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following cardiac catheterization, angioplasty, and coronary stenting. 

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: Upheld

Diagnosis:  Skeletal Class I, Maxillary and Mandibular Crowding, Deep Bite, Excessive Overjet and Impacted Right Maxillary Canine.
 
Treatment:  Orthodontic Treatment

The insurer denied the Orthodontic Treatment.  The denial was upheld. 

This is a young female patient who consulted an orthodontist for an evaluation.  Upon examination she was noted to have skeletal Class I, maxillary and mandibular crowding, deep bite, excessive overjet and impacted right maxillary canine.  She has completed the HLD index as required, and the orthodontist has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated.

To assess for severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation (HLD) 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. 

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care.  This reviewer concurs with the findings of the insurer of attaining 12 points on the HLD index (6 points overjet, 4 points overbite, 2 points labiolingual spread).

Regarding the validity of the HLD Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.  Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

Based on the above, the medical necessity for Comprehensive Orthodontic Treatment of the Adolescent Dentition is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class l, Normal Vertical Growth Pattern, Permanent Dentition, Moderate Maxillary Crowding, Moderate Mandibular Crowding, Moderately Excessive Overjet, and Deep Impinging Overbite with Severe Soft Tissue Damage
 
Treatment: Orthodontic Treatment

The insurer denied the Orthodontic Treatment. The denial was reversed.  

This is a young female patient who has skeletal Class I malocclusion, moderate maxillary and mandibular crowding, excessive overjet and deep impinging overbite who has a Handicapping Labiolingual Deviation (HLD) index of 17 points.

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 HLD 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. 
Regarding the validity of the HLD Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  


Based on the above, the medical necessity for Comprehensive Orthodontic Treatment of the Adolescent Dentition and Periodic orthodontic treatment visit is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite; soft tissue trauma
Treatment: Braces

The braces are medically necessary.

The patient exhibits a deep bite with soft tissue trauma to his palate. This is considered an automatic qualifying event on the handicapping score sheet. Therefore, the patient has a medical necessity for orthodontic treatment and coverage.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: PAX 2 gene mutation and mitochondrial disorder/Seizures
Treatment:Skilled Nursing Care in the home up to 14 hours/day x7 days/week

Summary:
While the mother has been trained in her daughter's care, in this type of emergency situation where timing and decision making are critical and may be the difference between life and death, she cannot be expected to perform at the same level as an experienced nurse. In addition to the complexity of this child's airway issues, she is also a post-transplant recipient requiring close monitoring of fluids, monitoring for signs and symptoms of infection, and precisely timed medication administration. Finally, she has history of refractory seizures, has undergone multi-lobectomy surgery, and remains on multiple anticonvulsant medications. She requires close monitoring for any signs and symptoms that may indicate need for rescue seizure medications. In the absence of round-the-clock nursing services, 14 hours per day 7 days per week is an acceptable minimum and certainly medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychosis
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

She was brought to the emergency department by EMS following a disturbance at home. The patient's husband or boyfriend called EMS as she had not been taking her medications and, according to him, tried to run away. 

An HPI (history of present illness) update states that the patient wanted to meet a man who told her telepathically that he was waiting for her.  She admitted that she was inconsistent in taking her medications.

A group note states the patient was attentive but barely spoke. She was euthymic and there was no overt evidence of psychosis. An HPI update on that day described the patient as pleasant but psychotic. She described various delusions from the past and currently talked about having a snake inside of her. She stated that she could not figure out what is real or not. The possibility of depot medication was discussed. 

At the time of admission, the patient was acutely psychotic and delusional. She was irrational and attempted to wander the streets in an unsafe manner. Although the patient improved rapidly, and by early 2019 showed no signs of overt psychosis, the additional time was necessary and appropriate to monitor her stabilization, avoid regression and readmission, and assess her response to depot medication
Appeal type: Medical necessity
Decision: Upheld

The patient presents to the dental office for evaluation and treatment of tooth #3, 30 and 31.  From the documentation there is no indication that there was any carious disease diagnosed, any pulpal pathology, any cuspal loss, nor any reason for the planned treatments.  Radiographic documentation does not display any caries, pulpal disease, periapical periodontal disease, nor any loss of cusps or failed restorations.
The health plans determination of medical necessity is upheld in whole.
There is no indication that there was any carious disease diagnosed, any pulpal pathology, any cuspal loss, nor any reason for the planned treatments.  Radiographic documentation does not display any caries, pulpal disease, periapical periodontal disease, nor any loss of cusps or failed restorations. Hence, none of the planned treatment for teeth #3, 30, and 31 is medically necessary.