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

Diagnosis: Idiopathic short stature. 
Treatment: Nutropin AQ Nuspin 20. 

The insurer denied Nutropin AQ Nuspin 20. 
The determination is upheld. 

The patient had initiated growth hormone (GH) therapy for idiopathic short stature. She has a history of anxiety and nocturnal enuresis and receives Celexa. Mid-parental target height is 63 plus/minus (+/- 3.5) inches. Pre-treatment height was 141.6 centimeters (cm) (height standard deviation score (SDS) -2.11) and weight was 30 kilograms (kg) (SDS -2.56). Provocative GH testing to arginine and L-Dopa revealed a peak GH response of 18 nanograms per milliliter (ng/mL). 

The patient stood 151.1 cm tall and weighed 36.5 kg. She had Tanner 4 breast development and Tanner 3-4 pubic hair. She had menarche. Insulin like growth factor-1 (IGF-1) level was 431 ng/mL and insulin-like growth factor binding protein-3 (IGFBP-3) was 4437 micrograms per liter (ug/L). GH therapy was denied upon a change in insurance. Resumption of GH therapy (Nutropin AQ Nuspin 20) is being requested and is under review for medical necessity. 

It is not medically necessary for this patient. 

The patient had normal results on provocative GH testing and her bone age was not delayed more than 2 SDs compared to chronological age. There was no evidence of poor growth velocity; thus, the patient did not have findings consistent with GH deficiency and does not meet medical necessity criteria for GH treatment based on general standards. Based on the patient's pre-treatment bone age and height measurement, the Bayley-Pinneau estimate of adult height was 60.5 inches, not short enough to qualify for the Food and Drug Administration (FDA) -approved indication of idiopathic short stature. 

The patient's growth accelerated after initiation of GH; however, her puberty progressed at the same time and her weight increased significantly; thus, improvement in growth cannot be attributed to exogenous GH treatment alone. 

The patient's height of 59.5 inches is already above the cutoff for treatment of idiopathic short stature while she continues to have open epiphyses; thus, resumption of GH therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron deficiency anemia
Treatment: Venofer
The insurer denied the Venofer.
The determination is upheld.

The patient has iron deficiency anemia due to menstrual losses. She  has previously received Venofer with a benefit. She currently has a hemoglobin of 10.2 grams per deciliter (g/dL), ferritin of 52 nanograms per milliliter (ng/mL), and iron saturation of 9%. The patient is stated to be tired and lightheaded. The patient has previously failed oral iron. There is no documentation indicating the patient has chronic kidney disease or that she has had an allergic reaction to another iron product. Additional Venofer has been requested. The health plan has denied Venofer but has approved Injectafer. The medical necessity for Venofer is under review.
The Venofer iron infusion is not medically necessary. The plan has approved Injectafer. There is a paucity of data indicating that Venofer is a superior parenteral iron agent in the setting of a patient without chronic kidney disease, who is not pregnant, and who has not failed another product due to an allergy. In their comparison study of these two products, Christoph, et al noted "...Ferric carboxymaltose has a comparable safety profile to iron sucrose but offers the advantage of a much higher iron dosage at a time reducing the need for repeated applications and increasing patients' comfort. Ferric carboxymaltose is the drug of choice...".
Support in the peer-reviewed literature, national guidelines, and by the authors of UpTodate is lacking and, for these reasons, medical necessity cannot be established for Venofer in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung Cancer. 
Treatment: Proton Beam Therapy. 

The insurer denied proton beam therapy. The health plan's determination is upheld. 

This patient is a woman with a history of pulmonary fibrosis who now has been diagnosed with a stage IIIB non-small cell lung carcinoma. She is not a surgical candidate. Radiation therapy with concurrent chemotherapy is recommended as definitive treatment and proton beam therapy is being requested. 

Proton beam radiation therapy is not medically necessary for this patient. 
Proton beam radiation therapy for this patient is not medically necessary. Proton beam radiation therapy has a lack of any significant clinical data published in peer reviewed journals supporting the efficacy or safety of this approach of treatment over standard photon beam radiation. There are multiple studies published that are small and non randomized stating the potential of proton beam radiation and also stating the need for randomized trials to be completed and published in peer reviewed journals to show the benefits and safety of proton radiation for non small cell lung carcinoma. Until these ongoing clinical trials mature and published, Proton Beam Radiation Therapy for patients with this clinical scenario is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of multiple substance use disorders (alcohol, cocaine, cannabis and opiates) who was admitted to an inpatient detoxification unit. He had a previous history of using opiates and had been receiving Suboxone up until early 2019. He was not currently on Suboxone and did not report any recent opiate use. Consistent with his history his blood was negative for alcohol and his urine was positive for only tetrahydrocannabinol (THC) and cocaine. He reported a history of depression and post-traumatic stress disorder (PTSD) but reported being on medications, in psychotherapy and that his medications were effective. He did not report any psychotic or depressive symptoms on presentation and denied suicidal ideation. The health plan's determination is upheld. The patient had relapsed on substances three weeks prior to this admission after being clean for fifteen months.  He had a psychiatric history but was stable psychiatrically on his medications and had outpatient treatment in place. He had no serious/uncontrolled medical issues. There is no information indicating that he was using in hazardous situations. He had no history of serious withdrawal and his initial CIWA was consistent with mild withdrawal. His pulse was normal despite an alcohol level of zero as his last drink was the day before. His systolic blood pressure reading was only very mildly elevated despite reports in the chart that he had untreated hypertension. This reviewer completed a Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) with the information obtained from the chart documentation; the result was a recommendation for outpatient services with ancillary withdrawal support services. This is also consistent with the current literature and clinical standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease
Treatment:  Increase in PCA services to 168 hours/week 

The proposed treatment of an increase in PCA services to 168 hours/week is deemed medically necessary. 

This is a male with a history of Parkinson's disease and associated cognitive impairment, gait ataxia and increased fall risk.  For these reasons, he requires assistance with the majority of his activities of daily living (ADLs).  Despite a recent clinical assessment completed in earlier in the year, which determined that the patient's abilities to complete his ADLs had remained the same since his prior assessment, additional documentation from the patient's primary care physician states that due to the patient's homebound status, cognitive/physical impairments and gait ataxia related to Parkinson's disease, he requires direct supervision/assistance of all ADLs; especially with transfers and ambulation.  The currently approved plan of 59.5 hours/week is not adequate to meet the patient's current needs.  For these reasons; the proposed treatment of an increase in PCA services to 168 hours/week is deemed medically necessary to better assist with the patient's ADLs.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of diabetes, hypertension, and alcohol abuse who presented to the hospita. The patient presented with nausea, vomiting, and abdominal pain. The patient reported that his symptoms had been ongoing for the past two days and the patient attributed them to alcohol withdrawal. The patient stated that the last drink was three days prior to presentation. Vital signs showed blood pressure 171/108, heart rate 102, respiratory rate 20, and temperature 98.9F. On physical examination, the patient appeared uncomfortable in the stretcher, heart was rapid, breath sounds were normal, abdomen was soft and nontender, and there were no cranial nerve deficits noted. The patient was admitted for alcohol withdrawal and uncontrolled hypertension. 

The health plan's determination is overturned. The inpatient stay is under review. The patient was being treated for alcohol withdrawal and already had tachycardia and hypertension at the time of presentation. Alcohol withdrawal is associated with seizures, hemodynamic instability, sepsis, and respiratory failure, and has a high rate of morbidity. Delirium tremens is a major comorbidity that develops in some of these patients during withdrawal. The uncontrolled hypertension was also a complicating factor that increased his risk of an adverse event. The patient required an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head injury
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a child that presented to hospital upon transfer from his Primary Care Provider's office after suffering a fall from a chair onto a concrete floor which occurred on the day prior to presentation. There was no loss of consciousness. On the day of presentation, the child reportedly vomited three times. 

On arrival, the child appeared tired. There are conflicting reports whether the child reported headache. The child vomited once in the Emergency Department. Vital signs were normal. Physical examination showed a left posterior scalp hematoma which was tender to palpation. CT of the head showed a linear occipital skull fracture without evidence of intracranial hemorrhage or injury. 

The patient was admitted to acute inpatient level of care. Neurological checks were ordered every four hours. Admission orders included intravenous fluids and analgesic medication of Tylenol. Neurosurgery was consulted and saw the patient later that day. Neurosurgery recommended discharge from a neurosurgical perspective and outpatient follow-up. No surgical intervention was recommended. The patient was discharged. 

The patient suffered a skull fracture with a scalp hematoma. There was no intracranial injury on CT. The fact the patient vomited but had normal neurological examinations is consistent with a mild concussion. The patient did not require acute inpatient level of care for the duration of the admission. The patient could have been treated at a lower level of care without compromise of patient safety or the quality of care rendered. 

The care that the patient would have received at a lower level of care, such as observation, would have been identical to the actual care received. 

There is no published evidence that admission improves quality of care for children with isolated skull fractures and symptoms consistent with mild concussion. The published literature regarding isolated skull fractures in children questions the need (even with this documented injury) of inpatient admission. Many can safely be discharged from the Emergency Department. In this case, a short period of observation with treatment with antiemetic medication and neurological examinations was appropriate.  

The hospital through its agent states the child showed signs of severe concussion including inability to tolerate liquids. The child was admitted to the ward for close monitoring and frequent neurological checks. This is inconsistent with the history and examination. The patient did not develop vomiting until the day following injury. The patient had normal neurological examinations and signs of mild (but not severe) concussion. Neurological checks every four hours would not be considered frequent (frequent would be considered every one to two hours). A brief period of observation would be adequate for the neurological examinations and to obtain neurosurgical consultation. Neither of these requires acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. Treatment: Inpatient hospital. The insurer denied inpatient stay. The denial is upheld.

The patient is a female with a history of cervical cancer and Rheumatoid arthritis who presented with one day of blood draining from her left nephrostomy tube. She denied dysuria, frequency, fevers, chills, nausea, vomiting or diarrhea.
Her vital signs showed that she was afebrile with a blood pressure of 109/71, a heart rate of 100, a respiratory rate of 16 and a room air oxygen saturation of 99%. On exam she was not in any acute distress with minimal tenderness around left nephrostomy tube insertion site. Labs showed a creatinine of 0.72, a white blood cell (WBC) of 8.2, and a hemoglobin of 9.7. A renal ultrasound showed bilateral hydronephrosis, left greater than right. The right nephrostomy tube continued to function normally. She underwent bilateral nephrostomy tube changes. Her urine culture grew Escherichia (E.) Coli, and she was started on Rocephin and then changed to oral Vantin for discharge. She was considered stable for discharge. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medical necessary based on the documentation provided. The patient presented with a dislodged left nephrostomy tube. She was hemodynamically stable; She did not have acute kidney injury. She did not have severe electrolyte or metabolic abnormalities. She did not have acute blood loss anemia. She was diagnosed with a urinary tract infection, but she did not have bacteremia nor was there documentation that she required prolonged intravenous (IV) antibiotic therapy. She underwent bilateral nephrostomy tube changes which is a procedure which does not require an inpatient level of care, and there was not documentation that she had complications that required inpatient management or monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Universalis
Treatment: Xeljanz 5 milligrams 30 per 30 days
The insurer denied coverage for Xeljanz 5 milligrams 30 per 30 days
The denial is overturned

The patient is a female who has a diagnosis of alopecia universalis.  She has failed therapy with squaric acid and intralesional kenalog injections.  She was treated a few years ago with oral Minoxidil and spironolactone as well as Xeljanz without significant hair regrowth.  The patient is noted to have acne vulgaris side effect associated with Xeljanz therapy, but no major side effects are otherwise documented in the provided medical records.  However, the patient has subsequently achieved remission from her disease following 4 years of Xeljanz therapy in combination with oral spironolactone and Minoxidil.  The patient is currently stable with her current regimen.  It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following 4 years of use which has resulted in disease remission without significant adverse effects.  As a result, the denial is reversed and the use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Xeljanz 5 milligrams 30 per 30 days is reversed.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell anemia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient in this case is a female with sickle cell anemia.  She presented to the emergency department with worsening pain. She had mild elevation in creatinine above baseline (increased to 1.3 from baseline of 0.8).  She was treated with intramuscular (IM) Dilaudid and was admitted to the hospital. Intramuscular (IM) Dilaudid was given rather than intravenous (IV) as the patient refused intravenous placement because she is a hard stick. During her hospital stay, the patient was continued on intramuscular Dilaudid and her course was complicated by elevated potassium that rose to 6.4 on the day following admission.   This was treated with insulin / intravenous fluid / calcium gluconate given twice, with subsequent improvement.  She also received Kayexalate. Records indicate that potassium has been chronically elevated though the elevation noted during this hospital stay was greater than she typically had in the outpatient setting. There were no electrocardiogram (EKG) changes noted.  

During the course of the patient's hospital stay pain improved and she was discharged.  Records indicate that she had severe pain when admitted and that she refused initial efforts to reduce her Dilaudid dose due to continued severe pain. She also had anemia during her hospital stay and was not transfused though it was recommended as her hemoglobin fell below seven. This was because she refused, again related to lack of intravenous access.

Yes, the proposed inpatient admission was medically necessary.
This patient had severe pain due to sickle cell anemia not controlled with oral pain medication at home.  Records indicate that pain remained severe despite initial treatment with intramuscular Dilaudid.  Intramuscular Dilaudid qualifies as parenteral administration even though it was not being given intravenously.  The patient also had hyperkalemia with a potassium over six that required treatment on two different occasions before it was brought under control.  The patient required prompt emergent treatment for hyperkalemia based on the degree of potassium elevation and also given that she had evidence of acute kidney injury at the time of admission.  In addition she had worsening anemia during her hospital stay with a hemoglobin less than seven, for which transfusion was felt indicated.  She refused transfusion, as noted above.  Given her documented severe pain that required continued treatment with intramuscular Dilaudid and her hyperkalemia during this hospital stay, it is most appropriate to conclude that acute care inpatient admission was medically necessary in this case.

As noted above, acute care inpatient admission should have been considered medically necessary in this case for the reasons outlined above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins
Treatment: Vein Treatment - Sclerotherapy or Echosclerotherapy 
The insurer denied Vein Treatment - Sclerotherapy or Echosclerotherapy. The health plan's determination is overturned. 

The patient is a woman with a 20 year history of symptomatic lower extremity varicose veins. The patient complained of varicose veins, burning, itching and pain in her left lower extremity. She used compression stockings.

A venous duplex exam of the left lower extremity demonstrated reflux of the left great saphenous veins and an incompetent left medial calf perforating vein. The patient was offered left great saphenous vein ablation and underwent radiofrequency ablation of the left great saphenous vein.

Vein Treatment - Sclerotherapy or Echosclerotherapy is medically necessary for this patient.

The patient has symptomatic left lower extremity perforating vein incompetence. She will benefit from treatment of her incompetent left lower extremity perforating vein. Incompetent perforating veins may be treated by surgical ligation, endovenous ablation using laser or radiofrequency energy, or sclerotherapy. Ultrasound guided sclerotherapy of incompetent perforating veins is the standard of care for the treatment of symptomatic perforating vein reflux.

The patient will benefit from the proposed treatment plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Humatrope. 
The denial is overturned. 

The patient is a male with short stature whose height fell to the less than (< ) 1st percentile after 3 years of age. Weight for height ratio is appropriate. He stood 120.1 centimeter (cm) (standard deviation score [SDS] -2.15) and weighed 24.6 kg (SDS -0.9). Mid-parental target height is 69.5 +/- 3.5 inches. The patient had a peak growth hormone (GH) response to clonidine of 16.56 nanograms per milliliter (ng/mL) and peak response to arginine of 0.55 ng/mL. The remainder of the workup revealed normal serum chemistries, except for an elevated alkaline phosphatase level of unclear etiology. The patient was initiated on GH therapy for idiopathic short stature. The subject under review is the medical necessity for Humatrope.  

The health plan's determination is overturned. 

There are different methods and computer programs available to assess adult height predictions and none of them are completely accurate. The prediction in this patient's case is hovering right at or below the 3rd percentile for United States (U.S.) adult men. In addition, besides using standard Centers for Disease Control and Prevention (CDC) criteria, comparing the patient to others in the U.S. population, in relation to his own genetic potential the adult height prediction is more than 2 standard deviations (SDs) below the genetic target height. He thus meets Food and Drug Administration (FDA) approval for GH. 

The patient's height is 2.5 SDs below the mean for age and gender, and his predicted adult height is <63 inches, more than 2 SDs below the mean for United States adult men and more than 2 SDs below his target genetic potential. All other causes of short stature have been ruled out. The patient meets criteria for GH administration for idiopathic short stature.