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

Diagnosis: Growth hormone deficiency

Treatment: Nutropin

The insurer denied growth hormone therapy. This denial was reversed.

This child has a history of mild autism. Per the early 2019 office visit note with the Pediatric Endocrinologist, the patient was there for follow up on his growth. He had been receiving growth hormone since the Fall 2018, but ran out.  There was a family history of short stature. The patient's height was 126.5 cm and his weight was 28 kg. His bone age had been recently interpreted to be between the 8 and 9 year old standards. Given his current height, using the tables in Greulich and Pyle, his predicted adult height was 62.5". The patient was noted to qualify for growth hormone with a diagnosis of idiopathic short stature.  

The 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 deviations (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 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 insulin like growth factor 1 [IGF1] or insulin like growth factor binding protein 3 [IGFBP3] or GH stimulation testing with a peak GH less than 10ng/ml. The patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration [FDA] approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score [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 standard deviation [SD]. The patient's height velocity and bone age are reported to a predicted adult height of 62.5 inches. The patient therefore met idiopathic short stature criteria. The patient is a continuing therapy patient. Continuation of growth hormone is indicated until the patient reaches final adult height. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

The patient is diagnosed with bipolar I disorder with a history of recurrent episodes of depression. The patient has been effectively treated with Vraylar (cariprazine) 1.5 milligrams (mg) daily since 2017 with tolerability and partial remission of symptoms.
Other prescribed medications include Lamictal, Cymbalta and as needed (PRN) use of low-dose Xanax. The patient had previously failed to benefit from treatment with aripiprazole, olanzapine, quetiapine and risperidone due to lack of clinical response or tolerability issues including the development of cardio-metabolic side effects (weight gain) and/or akathisia. The health plan's determination of medical necessity is overturned in whole. In this case, the requested benefit of Vraylar is clinically indicated and appropriate in keeping with prevailing standards of medical practice. The patient has reportedly failed several trials of alternative formulary medications without benefit or with adverse effects resulting in discontinuation of treatment. Vraylar has been providing reasonable clinical benefit since 2017. The use of Vraylar for the treatment of bipolar disorder is also consistent with product labeling and prevailing standards of medical practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, left great toe pain with swelling and drainage

Treatment: Inpatient admission; diagnostics; nail debridement

The insurer has denied inpatient admission. That denial was upheld.

This male patient presented to the ER with complaints of weakness and bleeding from multiple sites. He reported tripping, falling and injuring his left foot. His medical history includes diabetes, hypertension, lung cancer with metastases, cirrhosis, and pacemaker. The patient complained of worsening left great toe pain with swelling and drainage.  He was undergoing chemotherapy and stated he had a worsening of generalized weakness as well as symptoms related to the toe.   On admission, he was afebrile, his blood pressure was 122/59 and his heart rate was 118. Labs were significant for a lactate of 4 and hemoglobin of 7. He was admitted for anemia and positive lactate. Podiatry debrided the ingrown nails. 

The physical exam revealed the patient was in no apparent distress.  The left great toe nail-bed was lifted off with mild drainage.  It was recommended that the patient undergo multiple laboratory diagnostic studies.  Foot x-ray showed no focal lesions.  The chest CT had no acute findings.  He was recommended to undergo a blood transfusion. However, the patient did not wish to receive blood.  He was admitted for symptomatic anemia as well as a positive lactate.  Shortly after, the patient signed out AMA as he stated he would follow-up with his primary care physician.
The documentation does not detail there was a trial and failure of care at a lower level such as observation prior to admission.  Therefore, the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history remarkable for diabetes mellitus, hypertension, asthma, possibly an unknown type of cancer, ventral hernia repair, and amputation of two toes who presented to the emergency department with complaints of abdominal pain, nausea, and vomiting, which started four days before the date of admission.
The health plan's determination of medical necessity is upheld.  
This patient did not have clinical signs of acute peritonitis, small bowel obstruction, acute bowel ischemia, aortic dissection, abdominal aortic aneurysm, or any other findings that would necessitate admission at the inpatient level of care.
The patient responded to the treatment provided at the emergency room (ER), and also while on the medical floor, with fast resolution of his symptoms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brief Resolved Unexplained Event (BRUE).
 
Treatment: Admission to observation in the cardiac telemetry

The insurer has denied coverage for the inpatient hospital admission as not medically necessary.  Insurer stated that treatment in the ED was sufficient to manage his condition at that time.  The denial was overturned.

The patient is a male infant who was born at term with an uncomplicated newborn course.  He had been sick with diarrhea for three days and was found to be unresponsive and limp by his father.  The child was apneic for one minute with purple lips and perioral cyanosis.  The uncle performed cardiopulmonary resuscitation (CPR) in the home and Emergency Medical Services (EMS) was called and brought the child to an Emergency Room (ER) for evaluation.  This was the third episode of cyanosis that had been noted in this child in the past two months.  In the ER, the child was irritable and was found to have normal blood testing and chest x-ray.  The child was then transferred to another hospital for further diagnostic testing.  At the second hospital an EKG demonstrated tachycardia.  The ER physician decided to admit the child for observation in the cardiac telemetry unit with a diagnosis of Brief Resolved Unexplained Event (BRUE). 

The patient had the third episode of cyanosis and unresponsiveness in the past two months.  In addition, also according to UP TO DATE: Acute events in infancy including brief resolved unexplained event (BRUE), he had "Significant physiologic compromise during the event, based on a detailed description by the caretaker.  Concerning symptoms include generalized sustained cyanosis or loss of consciousness, and/or need for resuscitation by a trained CPR provider (more than just stimulation)."  During the period of observation in the ER, he was noted to have tachycardia.  The episode of facial color change and apnea with tachycardia raised the concern for a cardiac etiology for these episodes.  The child's recurrent episodes of cyanosis was concerning and the decision to admit the child for observation for an arrhythmia was appropriate and consistent with the standard of care for an infant with three unexplained episodes of cyanosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The patient is a female with a history of Lupus.  She was admitted through the emergency ward after an episode of loss of consciousness. 
After presenting, the patient had a ten-minute episode of right-sided face and arm numbness with slurred speech.  Prior to this and after the event, her examination was normal.  Her CT scan at presentation was negative for acute change.  She had MRI brain that was normal. 
The patient presented after a fall and experienced transient slurred speech.  Her MRI brain was negative.  The severity of her symptoms, the clinical presentation, and her risk factors did not warrant acute in patient level of care.  The work-up, treatment and monitoring could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis

Treatment: Dupixent (Dupilumab)

The insurer denied Dupixent (Dupilumab) SC injection. That denial was upheld.

The patient's has a past medical history of atopic dermatitis located on the arms, legs, trunk, right leg and right medial upper back. Medications include Prednisone and Triamcinolone acetonide. She has tried and failed topical triamcinolone and systemic/oral prednisone.  The provider states it would be impractical to use tacrolimus ointment due to the large body surface area involved and phototherapy would be difficult because of the patient's work schedule.  The provider also states the patient uses alcohol and therefore, cyclosporine would be contraindicated in this individual.  

Guidelines recommend using systemic immunomodulating agents in a subset of patients with severe atopic dermatitis recalcitrant to topical regimens and phototherapy.  Only a few randomized control trials have compared systemic treatments to one another, making it difficult to recommend one treatment over another. However, the current consensus among dermatologists suggests that cyclosporine, methotrexate (MTX), mycophenolate mofetil (MMF), and azathioprine (AZA) are the most effective. Cyclosporine is recommended rather than systemic corticosteroids as first-choice systemic therapy for atopic dermatitis and other severe eczemas in adults who do not have obvious contraindications to its use and who will benefit from a rapid resolution of symptoms. Contraindications to the use of cyclosporine include abnormal renal function, uncontrolled hypertension, uncontrolled infection, and concurrent malignancyThe efficacy of cyclosporine for the treatment of AD is supported by several randomized trials and systematic reviews.

The medical records do show tacrolimus ointment to be contraindicated due to the large body surface area involved.  Also, due to her work schedule, the patient would have difficulty with phototherapy.  However, the medical records do not show that the patient has tried and failed the formulary options. Based on review of the record and the medical literature, the use of cyclosporine is appropriate. Alcohol use is elective and a lifestyle choice; it is voluntary and can be discontinued, if desired.  It is not a contraindication to the medication. The requested drug is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Issue under review: Kombiglyze

Determination:
The Kombiglyze is not medically necessary.

Kombiglyze XR is a combination pill of extended-release metformin and saxagliptin, a dipeptidyl peptidase 4 inhibitor. The documentation does not support that the patient has tried and failed the preferred formulary alternatives Kazano, Janumet, and Janumet XR. The American Diabetes Association clinical guidelines do not recommend the use of Kombiglyze XR over these formulary alternatives, and specifically Janumet XR contains extended-release metformin and a dipeptidyl peptidase 4 inhibitor, which is consistent with standard of care in this clinical situation. Therefore, no, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of alcohol abuse who presented to the hospital with a loss of consciousness. He was thought to have a seizure that was witnessed by Police. He struck his head on the pavement per the report. Past history did include seizures for which he stated he was untreated. On physical examination, he was well developed, heart was regular, breath sounds were normal, cranial nerves were intact, and there were no sensory or motor deficits. Head computed tomography (CT) showed a small parietal subgaleal hematoma and no evidence of fracture. Cervical spine imaging was negative for fracture. Chest x-ray was negative for pneumonia. The patient was admitted with suspected seizure from alcohol withdrawal versus syncope. The plan of care included Keppra, electroencephalogram, brain magnetic resonance imaging (MRI), telemetry, urine toxicology testing, monitor for alcohol withdrawal, multivitamins, intravenous (IV) fluids, neurology consult, and surgery consult. The subject under review is the medical necessity of the inpatient stay. The health plan's determination is upheld, in whole. The inpatient hospital stay was not medically necessary, based on the available documentation. The patient needed further care for suspected syncope versus seizure but was hemodynamically stable, had no acute electrolyte abnormalities, had no acute EKG abnormalities, had no recurrent episodes of seizure, and no evidence of acute infection such as sepsis or acute metabolic abnormalities causing his symptoms. An inpatient level of care was not medically necessary. He was seen by neurology and surgery, and treated with IV fluids, labs, and imaging. He had no recurrent episodes of seizure or syncope.  The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with depression in the context of substance abuse with alcohol and general medical problems that had required hospital level treatment. The patient had initially presented for medical services after being found down and unresponsive near his car and emergency services were provided with admission for evaluation and treatment of his underlying conditions. He was medically cleared prior to his transfer for acute inpatient psychiatric services. The patient had elevated liver functions together with alcoholic liver disease. The health plan's determination is upheld. The patient did not present with acute general medical complications, or severe withdrawal symptoms or complications of co-occurring alcohol use disorder. Following admission, the patient had been treated for the mood disturbance and associated symptoms of anxiety/insomnia and functional impairments with improvement in symptoms and functioning; he did not require continued acute inpatient level structure or monitoring during the time interval under review.
Appeal type: Medical necessity
Decision: Upheld

The patient has multiple past medical history conditions and is requesting a total 8 hours a day of personal-care service hours, 7 days a week. The patient is currently approved for 7 hours per day, 7 days a week. The increase in hours was denied based upon lack of medical necessity. The health plan's determination is upheld.

The requested PCW services 8 hours per day, 7 days a week is not medically necessary for this patient. The patient has multiple past medical history conditions including diabetes, cerebrovascular disease, osteoarthritis, hypertension, anemia, dementia and urinary incontinence.
It is noted that the patient is alert and able to direct care, able to activate 911, and able to be left alone safely. The patient needs assistance with personal hygiene, walking and toiletry. The patient needs extensive assistance with bathing and dressing. The patient needs maximal assistance with meal preparation and is independent with eating.
It is noted that the patient's daughter-in-law prepares the patient's medicine weekly. The patient is able to take medicine otherwise independently with reminders.

According to the health plan, it was noted that the patient did not meet criteria for additional services because of personal-care service worker hours are able to meet her functional needs.
Based upon review of the Uniform Assessment System (UAS), it is noted the patient requires a total 5.65 hours per day 7 days week. The hours allocated to the patient, 7 hours a day 7 days a week is adequate to meet these needs. There are no additional services or tasks were noted that could not be completed during these hours. There is no notation in the documentation which shows an acute change in the patient's medical condition requiring more personal-care service hours. There is notation that the patient has increased arthritic pains and also psychiatric issues however the allotted time noted is sufficient to meet these needs. Additional service hours are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented with concerns of dizziness, general malaise, weakness, tiredness, vomiting and intermittent epigastric pain. He had been diagnosed with anemia 2 months prior and was treated with iron. At the time of evaluation, he had a heart rate of 127, blood pressure 101/52, and respirations of 22. He was noted to be pale and had gucaia positive stools. The health plan's determination of medical necessity is overturned in whole.
This patient presented with significant anemia and associated significant clinical finding to include tachycardia for age. In addition, he required two separate blood transfusions, had concerns for active blood loss in his stool and need for evaluation and monitoring of his condition. The blood transfusions had to be given slowly to ensure that the patient did not have issues with heart failure from the sudden increase in the volume of blood. This patient had significant tachycardia and a hemoglobin < 7.
The treatment needs of the patient in this case were not appropriate for a lesser level of care.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a female. She has a Class 1 malocclusion with protrusive maxillary incisors. She has treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to correct the crowding and protrusion. The comprehensive orthodontic treatment is under review. 

The health plan's determination is overturned. The comprehensive orthodontic treatment is medically necessary for this patient.

There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. Extraction of four premolars combined with orthodontics will make her teeth less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. For this reason, the orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cellulitis
Inpatient hospital stay

This is the case of a  patient with a relevant past history of right tibial fracture, who presented to the emergency department with presenting complaints of right leg swelling and bruising. On examination the patient has significant swelling, ecchymosis, and bullae on the right leg. The patient had tachycardia to a rate of 107 and had an elevated lactate of 3. An ultrasound of the right leg showed no venous thrombosis, but did show a large fluid collection within the leg. That fluid collection was visualized on the computed tomography scan as well, showing that it was deep to the gastrocnemius muscle head and had rim enhancement.
The patient was admitted for intravenous antibiotics and further management. Interventional radiology determined that the fluid collection could not be drained in Interventional radiology (IR). The patient improved and was discharged. The health plan's determination of medical necessity is upheld in whole. This patient was admitted with a suspicion for necrotizing soft tissue infection. The lactic acid level, tachycardia, and bullae were all concerning for that diagnosis. However, the diagnosis of necrotizing soft tissue infection can and should be made almost immediately or within hours of presentation. There is the expectation that this diagnosis would reveal itself before two midnights. Once ruled out, then the diagnosis becomes a likely cellulitis. An ultrasound of the right leg showed no venous thrombosis, but did show a large fluid collection within the leg. The fluid collection could not be drained in Interventional radiology, and the patient improved.
The patient meets neither InterQual nor Milliman Care Guidelines (MCG) criteria for inpatient admission for cellulitis, as  vitals were stable (the tachycardia improved quickly), the patient had not failed outpatient treatment, and could have been treated for a period of time at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Arthritis 
 
Treatment: Medication-Hyaluronic acid injections

The insurer denied coverage for the Hyaluronic acid injections. The denial was upheld.

This is a female patient with a history of right knee arthritis and other underlying medical conditions.  She had received treatment for her knee which did not provide benefit, including exercise, Celebrex, arthroscopic surgery and Euflexxa. She reported improvement after the injections.  She was evaluated by her physician who recommended additional injections of Hyaluronan. She had documented medical problems which excluded reconstructive surgery as a current option.   

The literature summarizing hyaluronic acid injections is well documented in the American Academy of Orthopaedic Surgery (AAOS) guidelines.  In general, the use of hyaluronic acid is not supported due to the fact that most studies show that it does not show superiority over other treatments, including placebo.  Even in the studies that show some patients reached a statistical improvement, it usually did not meet minimally clinically important difference (MCID) in their studies. The American Academy of Orthopaedic Surgery, in their guidelines, does not recommend the use of hyaluronic acid injections.  In their recommendations, they state the evidence is strong based on multiple studies with consistent findings for recommendations against the use of hyaluronic acid injections (AAOS Clinical Use Guidelines, 2015).

The carrier's denial of coverage for the requested Hyaluronan injection is upheld.  The medical necessity is not substantiated.