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

Diagnosis: Cardiac
Treatment: Inpatient hospital stay
The insurer denied the Inpatient hospital stay
The health plan's determination is upheld in whole. The inpatient stay was not medically necessary.

The patient was ruled out for acute coronary syndrome, had no arrhythmias of immediate concern, had no signs of orthostatic hypotension, and had no signs of respiratory failure. The troponin levels remained within normal limits. The imaging studies, including CT scan of the brain, were negative. During the entire hospital stay, the patient remained afebrile and hemodynamically stable. Clinical Institute Withdrawal Assessment (CIWA) score remained zero. Therefore, the review of the medical records did not reveal overwhelming evidence that the severity of the patient's clinical condition rose to the level of acute inpatient care.
The San Francisco Syncope Rule, which is a risk stratification tool, predicts the risk of serious outcomes at 7 days in patients presenting with syncope or near-syncope. Based on the calculations, this patient received 1 point because of the EKG abnormalities of unknown chronicity. This means that the patient did not belong to a low-risk group for serious outcomes. Therefore, the workup in the hospital was warranted and the patient could not be discharged home from the emergency department. Considering the patient's risk factors, including  past medical history of coronary artery disease, the admission to rule out acute coronary syndrome and cardiac arrhythmias was justified; however this could have been performed at a lower level of care. 
During the hospital stay, the patient was ruled out for acute coronary syndrome and had no arrhythmias of immediate concern to explain the syncopal episode. Therefore, a Holter monitor was placed. In addition, the workup performed in the hospital that included imaging studies and laboratory tests were reassuring. Taking into consideration these facts, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care. Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The admission at a lower level of care was  justified.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Inpatient Hospital

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

The patient is a male child with medical history significant for angioedema (worked up by Allergy and Rheumatology), moderate persistent asthma, and wheat allergy who presented to the emergency department (ED) with swelling of the right side of his upper and lower lips. The swelling worsened despite treatment with Benadryl. The family had been instructed to seek evaluation with every episode because of possibility of breathing difficulties.

The inpatient admission was not medically necessary. Angioedema is deep mucocutaneous swelling that occurs alone or in conjunction with urticaria following exposure. Angioedema typically involves the face, and in severe cases may involve the larynx. Gastrointestinal involvement is also common. Causes include physical stimuli such as exposure to pressure, vibration and temperature extremes; type I IgE-mediated reactions to foods (tree nuts, legumes, fish, eggs, milk, soy, wheat), medications such as penicillin and aspirin; aeroallergens such as pollen and dust mites, and organic substances such as latex; delayed hypersensitivity reactions as seen with some medications and food handling; autoimmune disorders; infections of all types; transfusions and serum sickness reactions; and direct mast cell degranulation from a wide variety of medications. Most cases, however, are idiopathic. Treatment involves second-generation histamine-receptor antagonists such as cetirizine, first-generation histamine-receptor antagonists such as Benadryl, corticosteroids, and if anaphylaxis is a possibility, epinephrine.
This male child with history of angioedema presented to the ED with acute onset right-sided upper and lower lip swelling, no difficulty breathing, and no gastrointestinal symptoms. He did not improve sufficiently in the ED to be safely discharged home, so he was admitted for overnight observation. While it was prudent to continue monitoring him for progression of symptoms, he was overall hemodynamically stable with no respiratory distress. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse
Inpatient Hospital

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

The patient is a man with a history of alcohol abuse who presented to the emergency department. He presented with alcohol intoxication. He reported drinking vodka daily for more than a week and stated that he was experiencing withdrawal symptoms. He may have also had an episode of falling or syncope. He denied suicidal ideation. In addition, he reported using marijuana. Review of systems was negative for fevers and chills. Vitals showed temperature 99.2 Fahrenheit, heart rate 94, blood pressure 124/81, and respiratory rate 17. 

The inpatient hospital admission was not medically necessary. The patient did not have evidence of significant withdrawal based on the available documentation. He appeared hemodynamically stable and there was no report of hallucinations or other significant mental status changes. The nursing notes also stated that the patient screened negative for suicide risk and no other acute withdrawal related concerns were noted. He could have been safely managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Opiate abuse disorder
Issue under review: Formulary exception for Suboxone 8-2MG SL film 
The insurer denied the Formulary exception for Suboxone 8-2MG SL film. 
The denial is upheld. 

No, the health plan should not cover the proposed formulary exception for Suboxone 8-2MG sublingual (SL) film.

The patient is a female with opiate abuse disorder being treated with Suboxone.

The patient is a female with a history of chronic pain and opiate abuse disorder who has been prescribed Suboxone.  There is no documentation that the patient cannot try or has failed formulary alternative buprenorphine- naloxone sublingual tablets.  There is no documentation in the literature that supports superiority of Suboxone film to buprenorphine-naloxone sublingual tablets.  Therefore it is not unreasonable for the patient to have failed the formulary alternatives prior to coverage of the requested medication. In a randomized multicenter trial, buprenorphine naloxone tablets were shown to have a better bioavailability then buprenorphine naloxone film and was found to be equally efficacious.  In another randomized controlled trial comparable clinical outcomes were seen between the two formulations. Given the above, the health plan should not cover the proposed treatment - formulary exception for Suboxone 8-2MG SL film.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth hormone deficiency (GHD)

Treatment: Zomacton 10 mg

The insurer denied coverage for Zomacton 10 mg. The denial is reversed. 

This patient is a female diagnosed with growth hormone deficiency (GHD). This request is for Zomacton. She started GH therapy (Zomacton) and she is doing well on it. She has been taking Zomacton with the needle free device. She has needle phobia. Her GH stimulation test with glucagon and arginine peaked at 3.9 with a baseline of 5.4. Her height velocity on therapy is reported to be 9.4 cm/yr. Her breasts are at tanner 2-3. Her bone age was 10 years at a greater specified chronological age. It was 8 years 4 months at a greater. Her MRI was normal. Her IGF1 was 175 (64-259); IGFBP3 was 4.22 (2.10-5.63). A couple of years ago she is at tanner 1. Her pretreatment height velocity is reported to be 4.214 cm/yr, -2SD.

Classic GH deficiency
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 sd below the mean 2) height more than 1.5 sd below the midparental height 3) height more than 2 sd below the mean and a height velocity over 1 yr more than 1 sd below the mean for chronological age, or a decrease in height sd of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 sd below the mean over 1 yr or more than 1.5 sd sustained over 2 yr. The biochemical criteria include low IGF1 or 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 10ng/ml. The patient met auxological criterion 2 as his height is more than 1.5 SD below target height. The patient also met auxological criterion 3 as his height is more than 2 SD below the mean and height velocity is more than one SD below the patient met both auxological and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary. 

The patient is a continuing therapy patient whose height velocity improved on growth hormone. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the medical necessity for Zomacton 10 mg, quantity 3 per 30 days is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Otitis media; Left ear pain 

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient is a male child who was brought to the Emergency Department (ED) by his mother with a complaint of left ear pain for several weeks, tactile fever for days and neck swelling.
On arrival at the ED, it was noted in the triage note that the patient was "jumping in triage" and "Happy and Playful." He was noted to be febrile with a temperature of 101.3F. Physical exam by the ED physician noted the patient as "alert and interactive." "Left tympanic membrane was dull with purulent effusion, slight proptosis of left ear, +mastoid tenderness on the left," "Large mobile lymph nodes on left anterior chain." A complete blood count obtained did show leukocytosis with a white blood cell (WBC) count of 27.8K. It was noted that a CT scan was ordered.

It was noted that on: "Unable to obtain CT at this time. Patient last ate at midnight...so unable to have sedation for CT at this time." "Attempted CT multiple times and not cooperative. Mother refusing sedation, ENT consulted." The progress note in the ED noted: "ENT came to see patient and feel this is more Otitis media and lymphadenitis. Will ADMIT?? for intravenous [IV] antibiotics and if improvement anticipate d/c home. The temperature maximum on admission was noted to be 98.4F.

It was noted that the Ear, Nose and Throat (ENT) suspicion for mastoiditis was low; therefore, no CT scan performed. An ultrasound performed showed reactive cervical lymphadenopathy. It was also noted that ENT did suction out purulent matter from the affected ear. The patient was reported to have received 2 doses of intravenous (IV) Rocephin and then switched to oral Augmentin and topical Cipro drops for the affected ear.

After reviewing the information provided alongside MCG 23rd Edition criteria for Pediatric Admission and Head & Neck Diseases, it suffices to deduce that this admission did not meet criteria for inpatient admission from as documented. The decision to deny is upheld. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:Digestive system/gastrointestinal
Treatment: Diagnostic Testing
The insurer denied: EGD
The denial is: Overturned in whole

The patient is a male under evaluation and management for gastroesophageal reflux disease (GERD). The patient had heartburn which occurred once per day. The patient has epigastric pain, heartburn, and throat discomfort. In addition, he has been experiencing daily morning vomiting with an associated 10 pound weight loss. The physical exam is normal. The patient is not obese. It was decided to put the patient on twice daily famotidine (never prescribed however), and check the stool for Helicobacter (H) pylori. The patient was seen a second time by his primary care physician (PCP) in the office for ongoing symptoms and lack of improvement with over-the-counter (OTC) omeprazole. One week after initial office visit the patient underwent an esophagogastroduodenoscopy (EGD).

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

The EGD was medically necessary. The EGD was not performed simply to evaluate acid reflux. The patient also had pain and daily vomiting associated with a significant amount of weight loss (10 pounds). The standard of care in light of these factors would be to perform an upper endoscopy (EGD) to look for an etiology such as peptic ulcer disease. This is supported by the American Gastroenterological Association.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Dental Disorder
Treatment Braces
The insurer denied Braces.
The determination is upheld.

The patient has a Skeletal Class I occlusion, mild maxillary crowding and mild mandibular crowding, mild overjet and mild overbite, mild posterior dental crossbites. The issue under review is the medical necessity of braces.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 7 with no auto qualifiers. Auto qualifiers include a cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Decipher Prostate Cancer Assay Gene Expression Test
The insurer denied the Decipher Prostate Cancer Assay Gene Expression Test
The determination is upheld.

The patient has a diagnosis of prostate cancer. He had a radical prostatectomy. His pathologic Gleason score was 3+4 and stage was tumor T2a, R1, N0. The patient has a detectable but low prostate-specific antigen (PSA). A GenomeDx Decipher test was ordered for risk stratification. At issue is the medical necessity of the requested testing.
The requested test is not medically necessary. The patient  had a radical prostatectomy. His pathologic Gleason score was 3+4. He has a detectable but low prostate-specific antigen. Decipher genomic classifier (GenomeDx Biosciences, San Diego, CA) is a genomic test that uses a whole-transcriptome microarray assay from formalin-fixed, paraffin-embedded prostate specimens. This signature was developed and validated as a predictor for clinical metastases after radical prostatectomy in men with adverse pathologic features. The main clinical utility of the test is to identify patients with adverse pathologic features who would benefit from salvage radiation therapy. Some studies have shown the test to accurately predict the risk of future metastases and disease specific mortality. Other studies have shown efficacy of this test in accurately predicting the patients who may respond to adjuvant radiation therapy. A majority of these studies are retrospective, non-randomized, case control series. However, data supporting clinical utility of this test in improving outcomes (prostate cancer mortality, overall survival and treatment side effects) is largely lacking. As such, it not considered a generally accepted standard for management of patients after radical prostatectomy.
The American Urological Association (AUA) Guidelines on Prostate Cancer, 2017 and European Association of Urology (EAU) Guidelines on Prostate Cancer, 2019 does not comment on the utility of the Decipher test. The National Comprehensive Cancer Network (NCCN) Guidelines on prostate cancer 2019 states, "The Decipher molecular assay can be considered for prognostication after radical prostatectomy." It does not recommend it as a routine in patients after radical prostatectomy.
American Society for Clinical Oncology Guideline on Molecular Biomarkers in Localized Prostate Cancer, 2019 states " The Expert Panel recommends consideration of a commercially available molecular biomarker (eg, Decipher Genomic Classifier) in situations in which the assay result, when considered as a whole with routine clinical factors, is likely to affect management. In the absence of prospective clinical trial data, routine use of genomic biomarkers in the postprostatectomy setting to determine adjuvant versus salvage radiation or to initiate systemic therapies should not be offered."
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Weakness/fatigue
Treatment: Inpatient Hospital. 
The insurer denied the inpatient hospital stay. The health plan's determination is overturned. 

The patient is a male with a history of alcohol use disorder (with prior withdrawal seizure and multiple prior detoxes), and prior pancreatitis who came to the emergency department (ED) for generalized weakness, tremors, malaise, and fatigue. His last use of alcohol was the day before.

The inpatient admission was medically necessary. The patient presented with alcohol withdrawal. On the basis of his presenting symptoms and prior history, an inpatient admission was indicated. Additionally, there was some concern for congestive heart failure (CHF) and acute pancreatitis which further increased concerns for this patient and the need for close monitoring.
The patient met criteria for an inpatient admission. He had a HR greater than 120 and was visibly tremulous on presentation, both are sufficient to meet criteria for severe withdrawal not manageable at lower level of care.
In addition, he met a number of other criteria noted in the literature cited below that would suggest he required inpatient care: prior seizures, multiple prior detoxifications, and lack of a reliable support network. Lastly, his low platelet count suggests more severe alcohol abuse and an increased risk of withdrawal seizures and DTs (delirium tremens).
Given all of the above, his risk of severe alcohol withdrawal was high, and he needed close monitoring for this with a high possibility of seizures, need for ICU care, and need for high/frequent dosing of IV sedative medications that cannot be provided on an outpatient basis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Cellulitis
Inpatient Hospital Stay
The insurer denied an Inpatient Hospital Stay.
The determination is upheld.


The patient has a past medical history (PMH) of asthma and intravenous drug abuse (IVDA) and was admitted with complaints of (c/o) right hand pain and swelling after attempted IV drug administration. Vital signs were unremarkable. On the physical exam, she had a non-toxic appearance and extensive right-hand cellulitis to the dorsal and flexor surface, extending from the proximal interphalangeal (PIP) of the third digit to the proximal wrist without flexor tenosynovitis was noted. Flexion and extension of the digits were grossly intact with normal sensation with full range of motion (ROM) and no evidence of abscess formation. Lab work was notable for leukocytosis. A right hand radiograph was unremarkable. Plastic surgery noted mild tenderness with well-perfused digits, low concern for compartment syndrome. The patient was diagnosed with extensive right-hand cellulitis and treated with broad-spectrum IV antibiotics, blood cultures, infectious disease (ID) /plastic surgery evaluation and IV fluids. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented with a right-hand cellulitis after attempting to inject cocaine. The patient was started on empiric IV antibiotics for cellulitis and evaluated by a hand surgeon, whose physical exam did not demonstrate any red flags with the ability to move digits and low suspicion for compartment syndrome and tenosynovitis. This patient did not meet systemic inflammatory response syndrome (SIRS) criteria and did not have any hemodynamic instability, animal or human bite, failure of outpatient (OP) treatment, immunocompromised state, infection over prosthesis or implanted device, orbital cellulitis, significant skin involvement, vomiting, severe infection or deeper infection, tissue necrosis, marked systemic toxicity or mental status changes. Overall, this patient was diagnosed with extensive right-hand cellulitis and treated with broad-spectrum IV antibiotics, blood cultures, ID/plastic surgery evaluation and IV fluids, and these services could have been safely and appropriately provided at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain 
Treatment: Inpaitnet admission
The insurer denied the inpatient admission.  
The denial is upheld.

The proposed treatment of inpatient admission is not deemed medically necessary. 

This is a female with a history of hypertension and chronic low back pain who presented to the ER for further evaluation/management of acute exacerbation of low back pain and facial numbness for ten days. Intake vitals were afebrile, hemodynamically stable with no evidence of profound bradycardia, tachycardia, hypotension or hypoxemia. Examination was notable for mild right sided facial droop, decreased right sided facial sensation, 4/5 right leg strength, dysmetria to the upper extremities and positive Romberg sign. Further workup including EKG, labs and head CT were within normal limits with no evidence of end organ damage including no stroke, myocardial infarction or arrhythmia. The medical records indicate that the patient was admitted to the inpatient medical service in stable condition where she continued to undergo diagnostic evaluation including head/neck CT angiogram, head MRI, orbit/face/neck MRI, repeat EKG, echocardiogram and continuous cardiac monitoring. Again, all studies were without critical findings including no evidence of stroke, myocardial infarction or arrhythmia. The patient improved after a period of observation and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, this patient's care could have been safely furnished in a less intensive setting without adversely affecting the patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.