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

Diagnosis: Panhypopituitarism
Treatment: Genotropin 0.8mg/0.25
The insurer denied the Genotropin 0.8mg/0.25.
The determination is upheld.

The patient has panhypopituitarism on the basis of an ectopic posterior pituitary gland. He receives growth hormone (GH) therapy, hydrocortisone, and thyroid hormone. He is status/post (s/p) treatment with testosterone for microphallus earlier during infancy and has a history of (h/o) bilateral orchidopexy for undescended testes. He presented with neonatal hypoglycemia and poor cortisol response to adrenocorticotropic hormone (ACTH) stimulation testing.
The patient self-injects with Genotropin MiniQuick. The plan approves Norditropin and Humatrope and there is no documentation of an adverse reaction to these other brands of GH therapy. Continuation of Genotropin therapy is requested and is under review for medical necessity.

Although GH therapy is medically necessary for treatment of GH deficiency in association with panhypopituitarism and ectopic pituitary, there is no medical necessity of one brand of GH over another brand. All brands of GH therapy are equally efficacious and have a low adverse effect profile. There is no documentation that the patient had an adverse reaction to Norditropin or Humatrope.
Therefore, the Genotropin 0.8mg/0.25 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee replacement.
Treatment: Inpatient admission.

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

This is a male patient with a history of hypertension, anemia and knee arthritis. He was admitted to the hospital for elective left knee arthroplasty. His post surgical course was non complicated.

No, the proposed inpatient admission was not medically necessary.
The medical records show a non complicated operation and post surgical course. There were no associated comorbidities which required additional management. 

The operation was of standard duration and blood loss. The vital signs were stable. There was no evidence of bleeding. The wound was satisfactory. The patient was able to tolerate oral pain medication. Physical therapy (PT) and social work services were involved. There was no need for special imaging or additional procedures. 

There were no extenuating circumstances to substantiate the admission and length of stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay
Treatment: Root Canal Therapy, Post/Core and Crowns for Teeth #10 and #11, Pre-service
The insurer denied the Root Canal Therapy, Post/Core and Crowns for Teeth #10 and #11, Pre-service
The denial is overturned.

The patient is a female requesting teeth #10 and #11 have root canal treatment and then crowns.

Yes, the proposed treatment is medically necessary.
The x-rays show the deep decay in both teeth #10 and #11. This would indicate the need for root canal procedures in both teeth with crowns placed afterwards. The patient has only five upper teeth present and has stated that she can't tolerate a partial denture. Extraction of teeth #10 and #11 would make the need for a denture stronger, which is exactly what the patient cannot tolerate. Keeping teeth #10 and #11 will give the patient just enough teeth to chew with and will not force her to wear a denture, which she can't. Extraction of these teeth is not the correct treatment; root canals and crowns in this case are medically necessary for the patient's health (i.e. being able to eat as normally as possible).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign Prostate Hyperplasia
Treatment: Transurethral Destruction Of Prostate Tissue: by Radiofrequency Generated Water Vapor Thermotherapy (53854)
The insurer denied the Transurethral Destruction Of Prostate Tissue: by Radiofrequency Generated Water Vapor Thermotherapy (53854)
The denial is upheld.

The patient is a male with symptomatic BPH (benign prostatic hyperplasia). Coverage for treatment with Rezum is requested.  He had tried alpha-blockers, but had side effects.  The prostate volume size was noted to be very large.  An MRI (magnetic resonance image) of the prostate had a 93 cc (cubic centimeter) prostate volume.  The AUASS (American Urological Association Symptom Score) was 32.

No, the health plan should not cover the proposed treatment.
The prostate volume exceeded the recommended limit of less than 80 grams.

AUA (American Urological Association) Guidelines state, "17 Water vapor thermal therapy may be offered to patients with LUTS [lower urinary tract symptoms] attributed to BPH [benign prostatic hyperplasia] provided prostate volume <80g [grams]; however, patients should be counseled regarding efficacy and retreatment rates."

No, the requested therapy is not likely to be more benficial.
The prostate volume exceeded the recommended limit of less than 80 grams.

The FDA (United State Food and Drug Administration) approval was, "Intended to relieve symptoms, obstructions, and reduce prostate tissue associated with benign prostatic hyperplasia (BPH). It is indicated for men greater or equal to 50 years of age with a prostate volume greater than or equal to 30cm3 [cubic centimeters] and less than or equal to 80cm3 [cubic centimeters]. The Rezum System is also indicated for treatment of prostates with hyperplasia of the central zone and/or a median lobe."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign Prostate Hyperplasia
Treatment: Transurethral Destruction Of Prostate Tissue: by Radiofrequency Generated Water Vapor Thermotherapy (53854)
The insurer denied the Transurethral Destruction Of Prostate Tissue: by Radiofrequency Generated Water Vapor Thermotherapy (53854)
The denial is upheld.

The patient is a male with large prostate, history of negative prostate biopsy and MRI (magnetic resonance imaging), extremely symptomatic despite alpha-blockers, retaining urine. The records indicate that the patient had a prostate volume of 100 grams.  He did not like high rate of retrograde ejaculation associated TURP (transurethral resection of prostate gland), and he decided to have Rezum. The patient underwent Rezum procedure.

No, based on the information provided, the health plan should not cover the proposed treatment.
The AUA (American Urological Association) guidelines recognize that Rezum is an approved, proven procedure and may be offered to patients with lower urinary tract symptoms attributed to benign prostatic hyperplasia provided that the prostate volume is less than 80 grams.  The documents provided indicate the patient had a very large prostate, and further documents provided indicated prostate volume noted to be 100 grams prior to Rezum procedure. This, the use of Rezum in this patient is not consistent with current standards of care, and should not be covered by the health plan.

No, it cannot be stated that this therapy in this patient with a 100-gram prostate is likely to be more beneficial, as it is not supported in the AUA (American Urological Association) guidelines.
There is documentation in the literature of the four-year durability with low incidence of side effects. An editorial comment in a recent publication notes, "When compared to alternative minimally invasive procedures such as Urolift, Rezum was shown to be less costly and to have fewer side effects."  A systematic review and meta-analysis substantiates the efficacy and low risk of adverse effects of the procedure. It has been established to be more effective than medical therapy.  However, recommended use is for prostate glands less than 80 grams.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign Prostate Hyperplasia
Treatment: Transurethral Destruction Of Prostate Tissue: by Radiofrequency Generated Water Vapor Thermotherapy (53854)
The insurer denied the Transurethral Destruction Of Prostate Tissue: by Radiofrequency Generated Water Vapor Thermotherapy (53854)
The denial is overturned. 

The patient is a male with known BPH (benign prostatic hyperplasia), large gland. He did not want medical therapy and TURP (transurethral resection of prostate gland) for his obstructive symptoms for fear of possible complications. He was specifically referred for a water vaporization ablation of the prostate (REZUM) that is sanctioned as a standard acceptable non-investigational procedure for his condition.

Yes, the health plan should cover the Transurethral Destruction Of Prostate Tissue: by Radiofrequency Generated Water Vapor Thermotherapy (53854).

It is deemed as a reasonable treatment, non-experimental for the patient's condition. It is not considered experimental, and it is a standard prostate procedure.

The procedure has been reviewed by an expert panel of Urologists and deemed meeting all requirements of the AUA (American Urological Association) Guidelines.

The procedure is comparable to other prostatectomy procedures.
Appeal type: Medical necessity
Decision: Overturned

Endocrine
Growth Hormone

Diagnosis: idiopathic short stature 
Treatment: Nutropin
The insurer denied Nutropin. The health plan's determination is overturned.

This is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her growth hormone (GH) stimulation test with arginine and clonidine peaked at 13.10. Her genitourinary (GU) was at tanner 1. Her Insulin-like Growth Factor 1 (IGF1) was 184. Her height velocity is reported to be 3.4 centimeter (cm) /year. 

Nutropin is medically necessary for this patient. 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 SDS (standard deviation score) 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 had a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Continued authorization of durable medical equipment (E0483RR x 3)

The insurer denied coverage for continued authorization of durable medical equipment (E0483RR x 3).

The denial is overturned.

The patient is a female with a history of asthma, seizures, recurrent pneumonia, cerebral palsy, developmental delay, and neuromuscular lung disease. The patient presented to her Pediatric Nurse Practitioner's office for follow-up care for asthma. Per the visit notes, the patient had been utilizing vest therapy as needed with illnesses. During this office visit, it was recommended that the patient maintains twice daily use of vest therapy for airway clearance and to prevent pneumonia. 

This patient also has cerebral palsy and frequent pneumonia, again with low chest wall muscle and this is complicated with the low tone of chest wall muscles, which in turn impairs the ability to clear the pulmonary secretions. This plugged mucous will act as a nidus for antibiotic resistant complicated pneumonia which can be life threatening in these patients. The patient also has probable microaspiration and this can further complicate the impaired clearance of lung. Moreover, since the patient has cerebral palsy, developmental delay, and impaired ability to cooperate for pulmonary function test/forced cough test or any other diagnostic tests, the best available evaluation is clinical evaluation by Pediatric Pulmonologist. The treating Pediatric Pulmonologist evaluating the patient has expressed concern to the point that she observed that after the vest therapy, the patient is doing clinically well and avoided potential hospitalizations. High frequency chest wall oscillation has been shown to improve pulmonary clearance in patients with non-cystic fibrosis bronchiectasis or chronic atelectasis. In studies, it has shown to improve the pulmonary parameters such as forced expiratory volume and forced vital capacity and even showed less inflammatory markers such as C-reactive protein. Also, it has shown decreased hospitalization in patients who use high frequency chest wall oscillation daily.

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

The insurer's denial of coverage for the continued authorization of durable medical equipment (E0483RR x 3) is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity.

Treatment: Saxenda.

The insurer denied coverage for Saxenda.

The denial is overturned.

This is a female patient with a medical history of depression, anxiety, hyperlipidemia, cystitis, morbid obesity, nontoxic multinodular goiter, prediabetes, and vitamin D deficiency.  The patient had been unable to lose weight despite dietary and lifestyle modifications. Saxenda was ordered.

Saxenda is medically necessary for this patient, as she has obesity and has tried and failed diet and lifestyle changes.  She has demonstrated adherence and attendance with a Nutritionist program for three months.  

Participants on liraglutide lost significantly more weight than did those on placebo and orlistat.  Mean weight loss with liraglutide 1.2-3.0 milligrams (mg) was 4.8 kilograms (kg), 5.5 kg, 6.3 kg, and 7.2 kg compared with 2.8 kg with placebo and 4.1 kg with orlistat and was 2.1 kg to 4.4 kg greater than that with placebo.  More individuals lost more than 5% weight with liraglutide 3.0 mg that with placebo or orlistat.  Liraglutide reduced blood pressure at all doses and reduced the prevalence of prediabetes with 1.8-3.0 mg per day (Astrup et al 2009).

"Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m2 [kilogram / square meter] or greater (obese) (1) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia)" (Food and Drug Administration Saxenda Package Insert).

"Liraglutide helps to induce and sustain weight loss in patients with obesity.  Its efficacy is comparable to other available agents but it offers the unique benefit of improved glycemic control" (Mehta A. et al. 2016).

"The final recommendations recognize that obesity is a complex, adiposity-based chronic disease, where management targets both weight-related complications and adiposity to improve overall health and quality of life.  The detailed evidence-based recommendations allow for nuanced clinical decision-making that addresses real-world medical care of patients with obesity, including screening, diagnosis, evaluation, selection of therapy, treatment goals, and individualization of care.  The goal is to facilitate high-quality care of patients with obesity and provide a rational, scientific approach to management that optimizes health outcomes and safety" (Garvey, W. T. et al. 2016).                                                 

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

The insurer's denial of coverage for Saxenda is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting, Confusion and Weakness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

This male presented to the emergency room (ER) for further evaluation/management of nausea, vomiting and weakness. Intake vitals were afebrile but blood pressure was moderately elevated to 175/98 milligrams of mercury (mmHg) and laboratory workup was notable for elevated serum creatinine of 1.3, along with evidence of moderate blood on urinalysis. Head computed tomography (CT) was negative for intracranial bleed. The patient was subsequently admitted to the inpatient hospital service for further evaluation/management. Abdominal/pelvic CT was done to rule out hydronephrosis and urinary stone disease. Neurology and Gastroenterology specialty consultations were also placed for assistance with further evaluation. The patient was started on intravenous (IV) fluids, given anti emetics and proton pump inhibitor with improvement in symptoms. He was subsequently discharged home. Appeal review requested for potential approval of inpatient hospital admission.

Yes, the proposed treatment, inpatient hospital admission is deemed medically necessary.

The medical records indicate that this patient was admitted to the inpatient medical service and required  intensification of services during the course of this patient's hospital stay. This included specialty consultations with Gastroenterology and Neurology and imaging workup with abdominal/pelvic CT. Hence, this patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. The requested service of inpatient hospital admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease
Treatment: Inpatient Hospital
The insurer denied the inpatient stay.
The denial is overturned.

The patient is a male with a past medical history significant for Crohn's disease, hyperlipidemia, and hypothyroidism who presented to the hospital with complaints of fever, chills, and body aches. These symptoms started one day before the presentation. These symptoms were associated with mild abdominal discomfort that the patient described as "gas pain."

The patient stated that his symptoms did not feel like his prior Crohn's flares, which were previously associated with sharp abdominal pain. The patient reported normal bowel movements and denied nausea, vomiting, diarrhea, palpitations, chest pain, cough, rhinorrhea, or sore throat.

Upon initial evaluation in the emergency department the patient's temperature was 101.5 Fahrenheit (F), heart rate 92 beats per minute (bpm), and respiratory rate 27 breaths/min.

In the emergency department, the patient received treatment with Zosyn, Flagyl, and two boluses of lactated ringers (LR) solution.

The patient was started on intravenous fluids as well as intravenous antibiotics. The patient was seen by a gastroenterologist who recommended the continuation of treatment with intravenous antibiotics. In the hospital, the patient was also seen by the infectious disease specialist who adjusted intravenous antibiotics and recommended to follow up on the culture results as well as results of the COVID-19 polymerase chain reaction (PCR). The COVID-19 tests came back negative. The patient's clinical condition gradually improved. All cultures remained negative. The patient was switched to oral antibiotics and discharged from the hospital. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient. 

This patient was immunocompromised and required treatment with intravenous antibiotics due to the presence of phlegmon associated with sepsis syndrome.

Systemic inflammatory response syndrome (SIRS), Sepsis, and Septic Shock Criteria is a risk stratification tool that defines the severity of sepsis and septic shock. Based on the calculations, the patient met sepsis criteria since the patient's temperature was greater than 100.4 Fahrenheit (F), heart rate exceeded 90 beats per minute, and the respiratory rate was greater than 20 breaths/minute. In addition, the patient had a possible source of infection seen on the computed tomography (CT) scan of the abdomen and pelvis described as phlegmon.

Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection.

In general, the treatment of sepsis includes perfusion restoration with intravenous (IV) fluids and sometimes vasopressors, oxygen support, broad-spectrum antibiotics, source control, and sometimes other supportive measures.

In order to provide treatment for patients with sepsis in the most efficient way in a timely manner, admission at the acute inpatient level of care is the most appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontitis
Treatment: D6010 (tooth #19, 30, 31) Surgical Placement Of Implant Body; Endosteal Implant 
D7953 (tooth #19, 30, 31) Bone Replacement Graft For Ridge Preservation
D7210 (tooth #19, 30, 31) Extraction
D6190 (tooth #30) Radiographic/Surgical Implant Index
The insurer denied the D6010 (tooth #19, 30, 31) Surgical Placement Of Implant Body; Endosteal Implant  
D7953 (tooth #19, 30, 31) Bone Replacement Graft For Ridge Preservation 
D7210 (tooth #19, 30, 31) Extraction 
D6190 (tooth #30) Radiographic/Surgical Implant Index.
The denial is overturned.

Yes, the proposed treatment is medically necessary.

The removal of teeth number (#) 19, #30 and #31 are needed as they are non-restorable. The bone replacement grafts are needed to prevent resorption of bone prior to implant placement. It is well documented that only partial bone fill of the alveolar socket occurs after an extraction. Studies show that three to four millimeters of both buccal-lingual and apicocoronal ridge resorption occurs within six months of extraction. Ridge preservation is a standard procedure that has been proven to preserve the alveolar bone and meets the standard definition of medically necessary. The options to restore function in this case are a removable denture or implants. Implants are the best choice. A partial denture has been shown to lead to the loss of adjacent teeth and have less chewing efficiency than implants. Implants are the standard of care and much more efficient than a partial. They are the closest thing to natural teeth, preserve the bone and are not susceptible to caries. The surgical guide is needed to accurately place the implant. Accuracy of implant placement using surgical templates is high and significantly more accurate than free-hand insertion.

Implants are the standard of care to replace missing teeth.