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

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent Syn 300, Pre-service. 

The insurer denied the Dupixent Syn 300. 
The denial is overturned. 

The patient is a female with severe atopic dermatitis, 20% (percent) BSA (body surface area) with IGA (Investigator's Global Assessment Scales) score of 4, treated with topical
steroids (triamcinolone, mometasone & hydrocortisone), Tacrolimus, Eucrisa, and
anti-histamines. The provider is requesting Dupixent. The patient is noted to be too
young for phototherapy and cyclosporine. 

Yes, the proposed treatment is medically necessary. 

The FDA (food drug administration) also approved dupilumab for the treatment of
patients aged six years and older with moderate to severe atopic dermatitis whose
disease is not adequately controlled with topical prescription therapies or when
those therapies are not advisable. This approval followed a phase 3, randomized,
double blinded placebo controlled trial that enrolled 367 patients to evaluate the
safety and efficacy of dupilumab in children (ages 6-11 years) for treatment of
atopic dermatitis. Significantly and clinically meaningful improvements in patients
signs and symptoms of atopic dermatitis as well as quality of life were reported. As
seen in adults, treatment in pediatric population was reportedly well tolerated with
the most commonly reported side effects including injection site reactions and
conjunctivitis. 

There are ongoing trials looking at the use of Dupilumab in children as young as six
months old. A phase 3 clinical trial by Regeneron began enrolling patients in 2015
and is looking at children between ages 6 months to 18 years and is assessing the
long term safety and efficacy of dupilumab for atopic dermatitis. In another 2-part
study, the safety, pharmacokinetics and efficacy of Dupilumb in patients 6 months
to less than 6 years of age is being evaluated. These studies have not revealed
any further safety concerns. 

Due to the severity of disease and lack of other ideal therapies, Dupixent is
appropriate and its use is supported by current medical literature. Cyclosporine and
other immunosuppressants would also place this patient who also has asthma at
higher risk of severe COVID infection, whereas Dupixent will not. This patient is too
young to receive a COVID vaccine. 

No, the heath plan did not act reasonably, with sound medical judgment and in the
best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Growth Hormone Deficiency (GHD)

Treatment: Norditropin Flexpro 10 milligrams per 1.5 milliliter pen injector

The insurer denied coverage for Norditropin Flexpro 10 milligrams per 1.5 milliliter pen injector.

The denial is upheld.

This is a teenaged male diagnosed with growth hormone deficiency (GHD). This request is for Norditropin. As reported; he started growth hormone (GH) therapy then he was off for a month and took GH again for one month; and since that time he is off GH therapy. His GH stimulation test with arginine and L-dopa peaked at 4. His magnetic resonance imaging (MRI) was normal. His pretreatment height velocity is reported to be 4 centimeters per year (cm/yr).

The growth chart reveals normal growth. Pretreatment height data show that height velocity prior to treatment was 5.1cm/yr which is normal.  His height after therapy was 142 cm (centimeters) (-1.77 SDS [standard deviation score]) mid parental height is 172.9 cm (-0.55 SDS).

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

Idiopathic Short stature

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines  [4, [5, [6, [7, [8, [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 does not have a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient therefore does not meet idiopathic short stature criteria. 

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary. The references provided are the most current/relevant to the case.

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

The insurer's denial of coverage for Norditropin Flexpro 10 milligrams per 1.5 milliliter pen injector is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender Dysphoria.
Treatment: Testosterone CYP 200mg/ml.
The insurer denied the Testosterone CYP 200mg/ml.
The denial is upheld.

The patient is an adolescent Gender Dysphoria female to male. This request is for Testosterone Cypionate. As reported; he has also not grown much in the last year while on hormone blocking treatment; he has only averaged growth of 2.3 to 3 centimeters per year each visit.

Approximately two years ago, the patient had his first Lupron depot. Due to shortage of 30 mg (milligrams) every 12 weeks Lupron, he did receive 11.25 mg (milligrams) once, and then he received 22.5 mg (milligrams) every 12 weeks formulation of Lupron. 

Earlier in the year, the patient's LH (luteinizing hormone) was 0.061, and estradiol was 2.7.

No, the treatment with Testosterone is not medically necessary.
The endocrine society clinical practice guidelines support the use of testosterone HRT (hormone replacement therapy) to treat female to male adult transgender patients with gender identity disorder [1].

Treatment with testosterone is standard of care for adult and late adolescent female to male transgender patients [2-4]. Outcomes have been examined, and there is no increase in mortality in treating female to male transgender patients with testosterone [3, 5].

The endocrine society clinical practice guidelines and the WPATH (World Professional Association for Transgender Health) guidelines do not recommend the use of testosterone in children under age 16 with gender dysphoria. The patient does not meet criteria for treatment based on age.

There are no studies supporting use of testosterone in transgender adolescents under age 16.

The request is therefore unproven and not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient, as the request is not medically necessary as described above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Infection
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient is a male whose admission is under review. The patient has a history of CAD (coronary artery disease), RA (rheumatoid arthritis), asthma, and HTN (hypertension). He presented with one day of right hand swelling and pain. He had been seen in another ER (emergency room) and sent home with diagnosis of arthritis, but his symptoms worsened, and he presented to hospital. No fever or chills were reported.

In the ER (emergency room), the patient's vitals were as follows: T (temperature) 97.0, P (pulse) 68, BP (blood pressure) 156/78, RR (respiration rate) 20. On general examination, the patient was noted to be obese and in distress due to pain. Examination of the patient's chest revealed crackles bilaterally. Examination of the patient's cardiovascular system and abdomen were normal. Examination of the patient's lower extremity revealed bilateral edema. Examination of the patient's right hand revealed swelling and erythema, with ROM (range of motion) limited due to pain. The patient's pain was noted to be 10/10.

In the ER (emergency room), the patient was thought to have cellulitis vs gout vs RA (rheumatoid arthritis) flare. He was started on IV (intravenous) ancef and IV (intravenous) pain control with morphine, and he was admitted. Shortly after admission, the patient signed out AMA (against medical advice).

Yes, the Inpatient admission was medically necessary.
The patient may have had a cellulitis. The admission criteria for cellulitis include presence of systemic symptoms (1), criteria the patient almost met (HR [heart rate] 98 and WBC [white blood count] 9.8). However, even without meeting these criteria, there was confusion as to what the diagnosis was, and gout and RA (rheumatoid arthritis) were also entertained, each of which has vastly different treatments. Finally, the patient was in severe pain, noted as 10/10, with visible distress on exam. Standard of care would require admission for pain control, and IV (intravenous) antibiotics until diagnosis was made clear.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
See above. By not admitting such a patient, the pain would likely not have been adequately controlled, and real diagnosis and treatment of the underlying condition delayed, causing unnecessary suffering for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: carcinoma-in-situ of the colon status post colostomy, gastro-intestinal hemorrhage, Atrial Fibrillation, morbid obesity, COVID-19
Treatment: Long Term Care Facility
The insurer denied the Long Term Care Facility.
The denial is upheld.

The patient is a male with history of general debility and weakness due to carcinoma-in-situ of the colon status post colostomy, gastro-intestinal hemorrhage, Atrial Fibrillation, morbid obesity, and was admitted to acute inpatient due to COVID-19 infection.

The patient was awaiting colectomy whenever his COVID status improved and INR (international normalized ratio) was also able to be at a level acceptable for surgery, which was postponed.

The patient's relevant medical history includes Atrial fibrillation, hypertension, morbid obesity, rectal carcinoma, chronic venous insufficiency, alcohol abuse, etc.

The patient was independent with most activities of daily living (ADLs).

No, the Long Term Care Facility was not medically necessary.
The patient was independent with most ADLs (activities of daily living). His care could have been accomplished at a lower level of care. He did not need to be in a long-term care for his needs during that period.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As stated above, the long-term care was not medically necessary, with clinical evidence of independence with most ADLs (activities of daily living). His needs could have been met at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He has a past medical history of GERD (gastroesophageal reflux disease). He was admitted to the hospital for acute non-perforated appendicitis. 

The patient underwent uncomplicated laparoscopic appendectomy.  The request is for approval for inpatient stay.  The patient was admitted. The request was previously denied by the health plan as they posit that the patient met criteria for observation rather than inpatient stay. 

No, the Inpatient Admission (as opposed to observation status) was not medically necessary. 

In considering the records concerning the patient, attending physician's recommendation, and applicable and generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

Clinical standards permit that this patient undergo observation status as opposed to inpatient status, as he was hospitalized for less than 48 hours and underwent acute treatment.  Observation status is generally acceptable for patient's undergoing uncomplicated non-perforated laparoscopic appendectomy.  There is no indication from the attending notes that the patient required inpatient as opposed to observation status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Mass 
Treatment: Inpatient level of care 
The insurer denied coverage for inpatient level of care. 
The denial is upheld. 

The patient presented with a history of a pelvic mass, who presented to the hospital for a scheduled laparoscopic removal of the pelvic mass. She underwent a laparoscopic salpingo oophorectomy, appendectomy and peritoneal biopsies. Diagnosis was consistent with mucinous adenocarcinoma unknown primary. She was admitted postoperatively for monitoring. She was discharged. 

The inpatient level of care is not considered medically necessary for this patient. The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. 

The patient presented with a diagnosis of a pelvic mass. She underwent an uncomplicated laparoscopy. A laparoscopy is an ambulatory procedure. 

According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for: 
1) Older patients (> 65), 2) Conversion to abdominal procedures, 3) Surgical complications, -]4) Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately. Her incisional pain was minimal. 
 
Please note that a laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. 

Based on the above, the inpatient admission was not medically necessary. 

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

Diagnosis: Bronchiectasis, pulmonary fibrosis. 
Treatment: Healthcare Common Procedure Coding System (HCPCS) code E1399 durable medical equipment, miscellaneous (Volara System). 

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code E1399 durable medical equipment, miscellaneous (Volara System). 

The denial is upheld. 

The patient has a history of mixed connective tissue disease, scleroderma, rheumatoid arthritis, Sjogren's syndrome, Raynaud's phenomenon, Guillain-Barre syndrome, bilateral lung abscesses, mycobacterium avium complex (MAC), bronchiectasis, and pulmonary fibrosis. 

Oscillatory positive expiratory pressure (PEP) devices combine PEP with high frequency oscillations to loosen respiratory secretions. In a systematic review of nine studies, although daily oscillatory PEP for four weeks was associated with improved health, compared with breathing exercises without a device, no difference was noted in amount of sputum expectorated, breathlessness, or lung function compared with other airway clearance therapies. Additionally, overall quality of evidence was deemed to be low. As such, further studies are needed to determine whether oscillatory PEP has benefits over other airway clearance therapies during exacerbations or with long-term use. Based on above findings, Volera System oscillation and lung expansion therapy is not medically necessary. 

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 Healthcare Common Procedure Coding System (HCPCS) code E1399 durable medical equipment, miscellaneous (Volara System) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient presented to the hospital with complaints of abdominal pain and fever.  The documentation indicated she was sent by gastroenterology for evaluation of symptoms.  Five weeks prior, she was diagnosed with the right kidney infection and admitted with sepsis.  She was discharged and did complete a course of antibiotics.  She stated however a few days later her fever returned.  She was given an additional course of antibiotics and her fevers resolved.  Her pain did improve however it has once again returned.  She complained of pain to the right side of the abdomen with associated dysuria.  She does admit to a history of substance abuse including IV (intravenous) drug use and has had 2 prior myocardial infarctions in the past secondary to cocaine use.  She has however been clean for a few years.  She also has a history of hepatitis C.  The physical examination revealed a temperature of 98.3 degrees with a heart rate of 68 beats per minute [bpm].  Oxygen saturation was 100% (percent) and her blood pressure was 112/56.  She did have mid and upper quadrant tenderness to the right with guarding.  The recommendation was made for laboratory diagnostic studies.  The laboratory studies revealed no significant findings.  There was evidence of epithelial cells in the urinalysis.  An ultrasound of the abdomen revealed no evidence of cholelithiasis or biliary ductal dilation.  The pancreas and aorta were not visualized due to overlying bowel gas.  A computed tomography (CT) scan revealed fatty infiltration to the liver.  The documentation indicated portions of the colon were not opacified, which limited evaluation.  There were no definite acute gastrointestinal (GI) related abnormalities otherwise identified.  There was a right adnexal cyst, and it was recommended she undergo a pelvic ultrasound.  The physician indicated there was no laboratory study detailing significant abnormalities.  The physician indicated given she has had 3 courses of antibiotics and continues with symptoms it was recommended she be admitted for an magnetic resonance imagining (MRI)/ magnetic resonance cholangiopancreatography (MRCP) for further evaluation.  She was treated with medication undergoing a GI consultation.  Throughout the remainder of the stay there were no significant adverse events noted.  She was discharged the following day with instruction to follow-up with gastroenterology.

Ultrasound (US) and computed tomography (CT) showed no acute abnormalities, there was no fever or signs of sepsis. The plan was to admit her for MRCP, but her liver chemistries were completely normal including an alkaline phosphatase of 40. This does not suggest biliary obstruction.

The patient could have been observed for symptom relief. Inpatient admission was not warranted. The health plan acted reasonably with sound medical judgement 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: Heart Failure

Treatment: Defibrillator vest

The insurer denied coverage for a defibrillator vest.

The denial is overturned.

The patient presented to the hospital with chest pain, shortness of breath and fatigue. Work up revealed heart failure with reduced ejection fraction, severe anemia and end stage renal disease and hypertension. Cardiac catheterization revealed no significant coronary artery disease. The patient required drainage of bilateral pleural effusions, renal replacement therapy and guideline directed medical therapy for reduced left ventricular ejection fraction (LVEF) (30-35% [percent]).

The insurer did not act reasonably, with sound medical judgment and in the best interest of the patient. The SCD-HFT [sudden cardiac death in heart failure trial] clearly demonstrated that such patients have a significant risk of sudden cardiac death and benefit from ICD [implantable cardioverter defibrillator] therapy (Reference 1).  Cardiologists must always attempt to treat reversible causes of cardiomyopathy prior to implanting an ICD (Reference 2).  During this period of diagnostic testing and treatment, patients are at risk for sudden cardiac death and must be protected.  External defibrillator therapy provides such protection while physicians determine whether treatment will result in an improvement in cardiac function.  Ultimately, if attempts at restoration of sinus rhythm and medical therapy failed to result in an improvement in this patient's LVEF and functional class then an implantable device would be recommended.  External lifevest defibrillator therapy provides protection from sudden cardiac death while physicians determine whether treatment will result in an improvement in cardiac function. Ultimately, such therapy is important as many patients respond to medical therapies and do not ultimately require permanent defibrillator placement. 

Wearable defibrillator therapy was medically necessary.  Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that wearable lifevest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment (References 3-4).

Based on the above, the medical necessity for a defibrillator vest is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 DM (diabetes mellitus)

Treatment: Replacement insulin pump (diabetes supplies) (procedure code E0784 x 1 unit)

The insurer denied coverage for replacement insulin pump (diabetes supplies) (procedure code E0784 x 1 unit).

The denial is overturned.

According to the medical records, the patient is a male with a history of Type 1 DM (diabetes mellitus) currently on insulin pump therapy and continuous glucose monitoring (CGM).  Over the last few months, he has noted that his CGM has been malfunctioning and not communicating with his pump.  He is requesting a new pump.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The patient is a long-term type 1 diabetic and needs both his pump and sensor to communicate in order to achieve an adequate and safe (A1c [glycated hemoglobin]) levels. The patient is outside his manufacturer warranty, also he has been having problems for the past two months with the device sensors not communicating properly.

Martin-Timon, et al., (2015), "CGMS [continuous glucose monitoring], that can detect hypoglycemia, represents an important technological advance on the methods used for self-monitoring of blood glucose, and they are welcome to both patients and clinicians [106]. The ability of CGMS systems is to advise patients when glucose levels fall too low or rise too high, and has the potential to reduce de-duration of hypoglycemia and hyperglycemia events."

Peyser, et al., (2015), "Use of an 80mg/dL (milligrams per deciliter) threshold setting for hypoglycemic alerts on the G4 Platinum (software 505) may provide patients with timely warning of hypoglycemia before the onset of cognitive impairment, enabling them to treat themselves for hypoglycemia with fast-acting carbohydrates and prevent neuroglycopenia associated with very low glucose levels."                                                         

Based on the above, the medical necessity for the replacement insulin pump (diabetes supplies) (procedure code E0784 x 1 unit) is substantiated. The insurer's denial is overturned.