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

Diagnosis: Atopic dermatitis

Treatment: Dupixent milligram (mg)/2 milliliter (ml) Pen (procedure code C9399)

The insurer denied coverage for Dupixent milligram (mg)/2 milliliter (ml) Pen (procedure code C9399)

The denial is overturned

 
The patient is an adult male with a diagnosis of atopic dermatitis.  The patient has failed multiple topical therapies and has partially responded to Dupixent every (q) 2weeks.  Due to residual disease, the physician is requesting weekly Dupixent dosing rather than switching to an alternative therapy.   

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary.  The patient has tried and failed biweekly Dupixent.   In 2019, Thibodeaux et al published "A review of dupilumab (Dupixent) in the treatment of atopic diseases." in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1).  Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2).  Therefore, it is appropriate, based on the patient's clinical findings and refractory disease, to approve weekly Dupixent in this patient.

The unique clinical circumstances to this particular individual that would make it medically necessary is that the patient is not currently controlled with biweekly Dupixent.  Therefore, weekly Dupixent is warranted in this case.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for prescription drug Dupixent 300 mg/2 ml Pen (procedure code C9399) (4 pens every 28 days) to be filled by a network specialty pharmacy on a date yet to be determined is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Idiopathic short stature.
Treatment:  Norditropin.

The insurer denied coverage for Norditropin.  The denial is overturned.

This is an adolescent who has been receiving growth hormone (GH) therapy, based on a diagnosis of idiopathic short stature. The annual recertification of growth hormone was recently denied by the insurer. The patient's pediatric endocrinologist appealed the denial indicating that at the start of GH therapy, the patient's height was at -1.96 standard deviation score (SDS) and insulin-like growth factor-1 (IGF-1) was below the mean, and that the mid-parental target height was 162.4 centimeters (cm) (-0.1 SDS), indicating the child was greater than 1.5 SDS below mid-parental target height at time of onset of GH therapy. GH stimulation testing was done with peak GH = 9.44 nanogram/milliliter (ng/ml), consistent with a diagnosis of growth hormone deficiency. Notes indicate that the patient was growing at 10.2 cm/year on growth hormone therapy, indicating a height increment of 2 inches in 6 months on therapy. The patient therefore is growing at criteria greater than required by the insurer's policy guidelines.  

The patient meets clinical criteria for a diagnosis of growth hormone (GH) deficiency with height more than 1.5 SDS below mid-parental target height, failed GH stimulation test with peak GH < (less than) 10 ng/ml, and IGF-1 below the mean for age (1, 2). The patient's response to growth hormone therapy indicates excellent responsiveness whether for a diagnosis of GH deficiency or idiopathic short stature (ISS) (3). Based on their short stature for the family as well as their GH stimulation testing and their response to therapy, continuation of GH therapy is medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Norditropin is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esophageal Foreign Body

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult who presented to the emergency room (ER) with dysphagia. He was hemodynamically stable. The abdominal exam was benign. A chest computed axial tomography (CAT) scan showed a foreign body in the esophagus and an incidental thyroid mass. The plan was for an endoscopy. A piece of meat was removed from the esophagus. The patient tolerated the procedure well and no complications were reported. He also had a low cardiac ejection fraction and there was a LifeVest arranged. An outpatient thyroid biopsy was planned. 

Milliman Care Guidelines (MCG) for Gastroenterology clinical indications for admission state that severe dysphagia is an Indication under certain conditions. These indications include caustic ingestion, severe dehydration, inability to manage secretions, hemodynamic instability, severe electrolyte abnormalities, and acute renal failure. The patient did not have these conditions. 

Milliman Care Guidelines (MCG) A-0203 lists indications for Upper Gastro-intestinal Endoscopy. Dysphagia with mechanical obstruction is an indication to do an endoscopy. However, Upper Gastro-intestinal Endoscopy is listed as ambulatory care. 

This patient required an urgent endoscopy. He tolerated the procedure well and without complications. It could have been performed with observation care. He did not meet Milliman Care Guidelines (MCG) guidelines for admission and endoscopy is an outpatient procedure. His cardiac and thyroid conditions were also amenable to outpatient management. Inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease. 
Treatment: Abdomen and Pelvis CT (Computed Tomography - pictures of inside belly area). 
The insurer denied coverage for Abdomen and Pelvis CT (Computed Tomography - pictures of inside belly area). 
The denial is upheld. 

The patient was diagnosed with Multiple Sclerosis (MS) and was having persistent gastroesophageal reflux disease (GERD) symptoms. The patient was having chronic headaches and was referred to a neurologist. Dietary advice was given for the GERD as well as omeprazole. An abdominal ultrasound was negative. The patient was seen by a gastroenterologist. The patient refused endoscopy and colonoscopy. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline A-0013 for Abdominal/Pelvic CT (computed tomography) Scan. Clinical indications for this exam include having an abdominal abscess, staging of cancer, evaluation of hernias, advanced liver disease, abdominal mass, abdominal pain suggestive of a serious condition, evaluation of pancreatitis, upper gastrointestinal (GI) bleeding after endoscopic testing, and abdominal trauma. The patient did not have these conditions. 

This patient is complaining of reflux. If the patient's symptoms are not responsive to proton pump inhibitor (PPI) therapy, then the patient would need to have an endoscopy. An abdominal and pelvic CT scan is not the correct test to evaluate GERD. The patient did not meet MCG criteria for doing a CT scan of the abdomen and pelvis. 

The health care plan acted reasonably and with sound medical judgment. An abdominal and Pelvis CT scan is not medically necessary. The denial is upheld. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Abdomen and Pelvis CT (Computed Tomography - pictures of inside belly area) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible stroke with history of end stage renal disease (ESRD)
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient was admitted for hypertension and slurred speech. Brain imaging was negative for acute intracranial process. The patient was evaluated by Nephrology due to history of end stage renal disease (ESRD) and was treated with routine hemodialysis and intravenous (IV) blood pressure medication on admission. The patient's condition responded to routine dialysis. The patient did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, no documentation of severe uremia such as encephalopathy or uremic bleeding. The patient had established dialysis access and did not require emergent vascular intervention.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission to is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain/vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay
the health plan's determination is upheld. 

The patient is a male who was admitted for abdominal pain and vomiting. He was noted to have an elevated creatinine and was started on intravenous (IV) fluid and anti-emetics. He underwent a Magnetic resonance cholangiopancreatography (MRCP) which was negative for significant biliary blockage. A chest X-ray was negative for infection. An electrocardiogram was negative for acute ischemia or arrhythmia. A computed tomography (CT) of the abdomen and pelvis was negative for acute intra-abdominal process.

The inpatient hospital admission was not medically necessary. The patient was admitted for dehydration and was noted to have elevated creatinine; however, his acute kidney injury could have been treated safely under a lower of care.

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN. This patient's kidney function improved in back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy.

In addition, he was hemodynamically stable and was able to tolerate oral diet. When taking into account the patient's exam, imaging, and lab findings, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who presented to the emergency department (ED) after an episode of chest pain, palpitations and mild dyspnea that occurred during exercise. His medical history was remarkable for hypertension and hyperlipidemia. Coronary computed tomography (CT) angiography showed a 65 percent (%) stenosis in the mid left anterior descending coronary artery (LAD). The patient was treated with aspirin. Cardiac catheterization was performed and showed a 70 percent (%) proximal left anterior descending (LAD) stenosis that was treated with a drug-eluting stent. The procedure was uncomplicated. Post-procedure he was admitted to the hospital. He remained stable overnight and was discharged. The medical necessity for an inpatient admission is at issue.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented to the hospital after an episode of exertional chest pain. He was hemodynamically stable, without acute electrocardiographic changes and with normal cardiac biomarkers. He underwent cardiac catheterization that revealed a significant coronary artery stenosis that was treated with a stent. The procedure was uncomplicated. While some period of observation immediately following percutaneous coronary intervention (PCI) is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission post-PCI for patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Foundation One Liquid CDx Genetic Testing
The insurer denied: Foundation One Liquid CDx Genetic Testing
The denial is upheld.

This is an adult female patient. She has metastatic positive estrogen receptor (ER) breast cancer. A request is made for Foundation One Liquid CDx genetic testing.

The requested health service was not medically necessary.

Only a small number of biomarkers have been proven to have effective therapeutic options in patients with advanced stage breast cancer. The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ACSO) guidelines recommend checking for high microsatellite instability (MSI-H), neurotrophic tyrosine receptor kinase (NTRK), rearranged during transfection (RET)-fusion, tumor mutational burden-high (TMB-H), and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) activating mutation, and estrogen receptor 1 (ESR1) mutation to help guide decision-making regarding treatment options in patients with advanced stage disease. The majority of genes assayed by Foundation One have no proven therapeutic correlate. The service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Moderate upper and lower crowding
Treatment: Braces and Adjustment of Braces
The insurer denied: Braces and Adjustment of Braces
The denial is overturned.

This patient is a school aged female. The request is for orthodontic benefits. She has moderate upper and lower jaw crowding. The prior denial was due to a handicapping index score of 12.

The requested health service is medically necessary.

The patient has an anterior tooth (#7, upper right lateral incisor) in crossbite. There is gingival attachment loss. The patient also has both of her permanent upper canines being impacted without needing extractions. Both of these conditions are automatic qualifiers for orthodontic benefits according to the handicapping index scale. Orthodontic treatment is medically necessary to correct these problems and the adjustments are needed to allow the treatment to proceed properly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Care: Cusp fractures were identified on teeth #2 and #15
Treatment: White glass with high gold content crown for teeth 15 and 2 and partial lower denture
The insurer denied coverage for: White glass with high gold content crown for teeth 15 and 2 and partial lower denture
The denial is: Overturned
Based on the submitted documentation which includes copies of chart treatment and progress notes, bitewing and periapical radiographs, narrative letter of support from Community Health Advocate, notarized affidavit in support of the treatment, narrative letter of support from Physician Assistant, complete medical record, literature review in support from JADA Vol 101, August 2000, additional peer-reviewed literature, and insurer correspondence, it appears that this patient presented for dental care. Cusp fractures were identified on teeth #2 and #15 with significant structural coronal loss. The dentist is requesting placement of full coverage crowns due to this significant tooth fracture. In addition, the dentist is requesting a mandibular removable partial denture to treat the partial edentulism and restore function. The insurer has denied the full coverage crowns and partial denture stating that the services are not medically necessary as the documentation did not demonstrate clinical findings to support the treatment, nor does this meet stipulated criteria and therefore the circumstance does not fulfill the insurers stated criteria for approval. 

Upon review of radiographs and chart progress notes, these support the recommended treatment. Teeth #2 and #15 both exhibit large cusp loss with coronal fracture. These teeth have adequate remaining coronal structure for support of full coverage crowns and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crowns which would have an excellent long-term prognosis with the recommended treatment. A mandibular removable partial denture would be a standard of care in addressing partial edentulism in the mandible. Further, the clinical situation meets the insurer criteria for approval.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for white glass with high gold content crown for teeth 15 and 2 and partial lower denture is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Bleeding
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.


This is a female patient with vaginal bleeding for two days who presented to the emergency department with headaches and said she felt lightheaded. Her hemoglobin was 8.3 and a pelvic ultrasound showed uterine fibroids. She was admitted as an inpatient for symptomatic anemia. She had incidental changes on her electrocardiogram (EKG) and a follow up echocardiogram (ECHO) was negative. She was given progesterone oral mediation and transfused 2 units of packed red blood cells (PRBCs). She was discharged the following day in stable condition. At issue is the medical necessity of an inpatient admission.
The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient.
The patient was a healthy female without significant comorbidities. She had vaginal bleeding, however, without severe anemia but was admitted for a blood transfusion. Her vital signs were normal and she had no hemodynamic instability. Her hemoglobin was 8.3. She received the blood transfusion without complication. She had no pulmonary, renal or hepatic complications. She could have been observed at a lower level of care as she was discharged less than 24 hours later. There was no need for acute, inpatient monitoring as there were no complications.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

The patient is a male who presented to the emergency department (ED). The patient presented to the ED with sudden onset of sharp pleuritic mid-sternal chest pain radiating to his back and associated with diaphoresis and shortness of breath. The pain started a couple of hours prior to presentation while laying down. He had shortness of breath while lying flat. The patient was smoking and using cocaine. The patient also was complaining of testicular pain. His chest pain was graded as 7-8/10. The patient reported cocaine use one day before.

The inpatient hospital admission was not medically necessary for this patient. The patient presented with chest pain. The patient was found to have cocaine in his urine. His ECG and troponin excluded acute coronary syndrome. Cardiology did not recommend any additional studies or procedure. The patient was treated with oral medications. The patient's condition and level of care did not meet criteria for an inpatient admission. An Observational level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Substance abuse
Substance abuse inpatient

Diagnosis: Substance abuse
Treatment: Substance abuse inpatient
The insurer denied Inpatient Admission: Medically Supervised Inpatient Detoxification
The health plan's determination is overturned. 

The patient is an adult male who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol and stimulant (cocaine) use disorders. The patient was using up to twelve beers daily together with $30 worth of crack cocaine three days per week.
The patient presented with mild alcohol withdrawal at the time of admission. Withdrawal symptoms included tremor, sweats, nausea, insomnia, irritability and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 5 with use of alcohol the morning before presentation. 

Inpatient Admission: Medically Supervised Inpatient Detoxification was medically necessary for this patient.
The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol and cocaine use disorder, and other services noted in the clinical summary, could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with a lack of insight, high risk for relapse and lack of a reasonable recovery environment. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin and nicotine replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.