Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple sclerosis. 
Treatment: J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams]. 

The insurer denied coverage for the Pre-Service request for J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams]. 

The denial is overturned. 

This is a female patient diagnosed with multiple sclerosis, migraines, and hypertension. 

The patient was diagnosed with multiple sclerosis and had tried Tecfidera.  However, after a couple of years, radiologic progression was noted.  The patient then tried Lemtrada and continued to have issues with gait and spasticity.  The patient was at high risk for progressive multifocal leukoencephalopathy (PML) and due to her being treated with immunosuppressive drugs was at high risk of contracting COVID-19 [Coronavirus Disease 2019]. 

The patient was seen for a follow-up via telemedicine.  There was difficulty with gait and spasticity.  On examination, gait showed difficulty with tandem/heel toe walking.  Given the pandemic and concerns of immunosuppression and implications for vaccination, the patient was recommended to hold off immunosuppressive treatment.  The patient was recommended for monthly intravenous immune globulin (IVIG). 

The patient has a history of refractory multiple sclerosis with significant issues noted by treating physician with gait and spasticity with recent treatment failures with Tecfidera and Lemtrada. She is felt to be at high risk for progressive multiple sclerosis and the treating physician notes the patient is at high risk for contracting COVID-19 secondary to chronic immune suppressive therapy. The treating physician wishes to proceed with treatment with monthly IVIG. IVIG is used to help combat multiple sclerosis relapses. By definition, the risk of PML would be mitigated with IVIG (which is typically used to treat PML). It would be a safe choice in this patient with refractory multiple sclerosis. Therefore the requested service is likely to be more beneficial than any other standard services. 

The carrier's denial of the Pre-Service request for J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams] should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple sclerosis. 
Treatment: J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams]. 

The insurer denied coverage for the Pre-Service request for J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams]. 

The denial is overturned. 

This is a female patient who has relapsing remitting (RR) multiple sclerosis (MS).  She has failed treatment with Tecfidera and Lemtrada.  Her MS specialist Neurologist has prescribed intravenous immune globulin (IVIG).  One rationale is that IVIG is not an immunosuppressant (unlike most other MS drugs) which makes it especially suitable for use during a pandemic and in a patient who is John Cunningham virus (JC virus) positive.  Additionally, the patient is trying to get pregnant and most MS drugs are contraindicated in pregnancy. 

There are several high quality peer-reviewed publications demonstrating that IVIG treats MS.1. 

This patient is the best candidate for the reasons listed above (pandemic, JC virus, failure of other medications, and possibility of pregnancy); IVIG is a good treatment for this patient. The patient's Neurologist believes this is the best treatment for this patient at this time and this reviewer concurs, IVIG is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of the Pre-Service request for J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams] should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Trauma/Injuries
Inpatient hospital

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

This patient is man who presented one day following a fall from a bicycle. He complained of left sided abdominal pain. His past medical history was notable for congestive heart failure, coronary artery disease with stents, and hypertension. He is treated with aspirin and Plavix as anticoagulation for the coronary stents. The emergency department (ED) evaluation identified normal vital signs. Glasgow coma score was 15. Oxygen saturation was 98%. He had a left flank hematoma without peritoneal signs. Hemoglobin was 13.5 g/dl. Imaging with computed tomography (CT) scan identified a 5.6 x 2.5 centimeter (cm) subcutaneous hematoma of the left lateral abdominal wall. There was no intra-abdominal injury. He was admitted to the hospital. 

The inpatient hospital admission was not medically necessary. This is a patient who fell from a bicycle and presented the following day for evaluation. He was clinically and hemodynamically stable at the time of presentation and remained so during the period of monitoring. He had a left abdominal wall hematoma identified on CT scan imaging, but had stable hemoglobin values. He did not require and emergent treatment or blood transfusion. He tolerated a diet and oral pain medications. The care and treatment provided could have reasonably been rendered at a lower level of care. This lower level of care would have permitted evaluation and follow up as provided and would have also permitted overnight observation. An inpatient stay was not required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient with history of Asthma and Polysubstance abuse (recent use of Oxycontin and Cocaine).  The patient is a smoker.  There is history of exposure to plaster dust at work.  The patient presented to the hospital with complaints of shortness of breath (SOB) which started after he inhaled some plaster dust at work.  The patient got some relief with inhalers at home.  The following day he developed shortness of breath (SOB) again and presented to the Emergency Department (ED).

Vital Signs at presentation to the ED were temperature (T) 98.9, blood pressure (BP) 139/95, heart rate (HR) 120, respiratory rate (RR) 28 and Oxygen (O2) saturations 94%.  The patient was in no acute distress.  The patient was able to speak full sentences.  No accessory muscle use is noted.  Lung exam revealed decreased breath sounds and bilateral wheeze.   The patient's labs were white blood cell (WBC) count 14,000, hemoglobin (Hb) 14.6, Electrolytes were within normal limits (WNL), Troponin was negative and electrocardiogram (EKG) showed no acute ischemic changes.

Venous blood gas (VBG) was 7.39/49/67, and chest x-ray showed no acute infiltrates.  The patient was treated with Steroids and Nebulizers and O2.  Singulair was added.

The patient was subsequently admitted to the hospital for asthma exacerbation.  He remained stable after admission.  Peak expiratory flow (PEF) improved to 250-280 from 150 recorded in the history and physical (H&P).  This patient was cleared for discharge on oral medications Prednisone, Advair and Singulair.

This patient did not need acute inpatient hospitalization.  He could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient remained stable after admission.  He was afebrile and hemodynamically (HD) stable.  He was not hypoxic. O2 saturations were 94-100%.  There was no pneumonia on chest x-ray.  The patient was tolerating oral intake.

PEF improved with treatment.  This patient could have been discharged home after a period in Observation status (which could last up to 48 hours).  This patient had improved on medications and was stable for discharge home on oral medications and inhalers with close follow-up in an outpatient setting.  

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematuria and Dysuria
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male was admitted through the emergency room (ER) with benign prostatic hyperplasia (BPH), hematuria and dysuria.  He was found to have acute kidney injury (AKI) (creatinine 1.6), hyponatremia, a urinary tract infection (UTI) and an eight centimeter computed tomography (CT) finding concerning for bladder cancer.  Vitals were as follows: temperature 97.5, pulse 76, and blood pressure 166/80.  A Foley catheter was placed and irrigated.  The white blood cell (WBC) count was 10,800.

Urology was consulted.  Post void residuals (PVRs) were 260-300 cubic centimeters (cc).  Urine culture had no growth.  Urology planned for an outpatient cystoscopy.

The post void residual (PVR) was 150 cubic centimeters (cc).  The patient was having difficulty voiding.  A catheter was placed and clots were removed.  He was able to void afterward without distress.

He had pain with urination.  The urine was clear.  The post void residual (PVR) was 137 cubic centimeters.

No, the proposed inpatient admission was not medically necessary.

An acute inpatient level of care was not required.  As there were no signs of complications, infection, excessive bleeding, or instability, an acute inpatient level of care was not necessary.  The care of this patient's comorbid conditions was routine.  An observation level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: Comprehensive Orthodontic Treatment (08660)
The insurer denied the Comprehensive Orthodontic Treatment (08660).
The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits.

Yes, the proposed Comprehensive Orthodontic Treatment (08660) is medically necessary.

The patient has impacted or "blocked out" maxillary left and right canines. According to the handicapping index scale, when there are impacted anterior teeth (which these are) and there is no indication for extractions, this is considered an automatic qualifier for orthodontic benefits. This case has medical necessity.

As stated above, due to the impacted upper canines, this case has an automatic qualifier for benefits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever/cough
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a boy with a history of alpha-1 antitrypsin deficiency who presented with fever, cough, and decreased oral intake. He was well until 3 days prior to presentation when he developed cough and congestion. He subsequently developed decreased oral intake and his urine output decreased. His fevers were initially 103-104F (Fahrenheit), and on the day of presentation went up to 105.3F. He was also irritable. Due to this extremely high temperature, his mother brought him to the emergency department for care.

The inpatient hospital stay was medically necessary for this patient.
This is a very young patient with an underlying medical condition of alpha-1 antitrypsin deficiency, who presented with extremely high fever, elevated inflammatory markers, and ill appearance. Alpha-1 antitrypsin deficiency is an inherited disorder affecting the lungs, liver, and skin. In the lungs, it causes chronic obstructive pulmonary disease with an elevated risk for infection and complications. At the time of presentation, this patient was described as ill-appearing, lethargic, and fussy, and had dry mucous membranes suggesting dehydration. His laboratory values revealed significantly elevated inflammatory markers, and these continued to be high during his hospitalization. He required the prompt initiation of antibiotics and intravenous fluids, along with close monitoring in an inpatient setting with additional treatments as needed.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of extremely high fever, elevated inflammatory markers, and an abnormal physical examination, and the need for prompt initiation of treatment with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyponatremia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of schizoaffective disorder, hypertension (HTN), traumatic brain injury (TBI), and diabetes mellitus type 2 (DM2) and was admitted due to hyponatremia. Of note, the patient was asymptomatic. The vital signs were unremarkable. The physical exam was notable for a normal neurological examination. Lab work showed a sodium of 126. The patient was diagnosed with hyponatremia secondary to Syndrome of Inappropriate Antidiuretic Hormone (Secretion) (SIADH) and treated with a nephrology consultation, free water restriction, intravenous (IV) Dextrose 5% in water (D5W) and frequent sodium checks. The patient's sodium over-corrected and the D5W infusion was adjusted. The patient was discharged  in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient was transferred from psychiatry unit after he was found to have incidental hyponatremia on a basic metabolic panel (BMP). The patient had a mild hyponatremia of 126. There was no associated headache, nausea, vomiting, anorexia, muscle cramps, confusion, cardio-respiratory distress, somnolence, seizures, coma, or neurologic symptoms. This patient had neither severe hyponatremia nor moderate/severe symptoms of hyponatremia. Overall, this patient was stable, responded to IV fluids and fluid restriction, had no neurologic symptoms, and could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld.

The patient is female with a history of neck and bilateral arm pain since a motor vehicle accident (MVA). A cervical magnetic resonance imaging (MRI) scan demonstrated a sizeable paracentral disc herniation at C5-6 with some mild remodeling of the spinal cord, although no signal changes. On neurological examination in the surgeon's office, the patient was noted to have variable degrees of bilateral arm weakness, graded at 4-/5 to 4+/5 in bilateral deltoids, biceps and triceps muscles with altered sensation in bilateral C6 dermatomes. No pathological reflexes were noted. Her symptoms had failed to improve with adequate attempts at conservative therapy and she was recommended to undergo an anterior cervical discectomy and fusion (ACDF) at C5-6. This was performed and no complications were noted. In the afternoon, she was evaluated by physical therapy (PT) and found to be lethargic (note mentions patient unable to keep her eyes open) and complaining of dizziness. Through the night she remained hemodynamically stable, with the lowest recorded vitals showing her blood pressure (BP) to be 95/54 with a heart rate of 72. Apparently, she continued to complain of dizziness and the physician's assistant (PA) ordered a bolus of 500 milliliters (ml) normal saline (NS) and increased the rate of her intravenous fluids from 75 milliliter per hour (ml/hr) to 100 ml/hr and the decision was made to admit her as an inpatient for continued monitoring. Her vitals continued to remain stable until her discharge the next day with no other interventions required. There was no order given to change the frequency of checking her vital signs, nor any mention of the need for monitoring in a more intensive care setting.


The health plan's determination is upheld. 

There is nothing in the records provided for review that supports the medical necessity of an inpatient status. She was not hemodynamically unstable, with the lowest blood pressure reading being 95/54 with no change in heart rate, oxygen saturation or clinical distress noted in the nursing notes. Other than the order for the normal saline bolus and change of intravenous fluid rate, there were no other orders given such as transfer to a more acute unit/floor, change in frequency of vital signs or any other nursing monitoring instructions. There is no bedside progress note at that time documenting hemodynamic instability. The vital sign monitoring and administration of the IV fluids including the bolus could have been safely and adequately continued at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine Headache. 
Treatment: Ajovy. 

The insure denied Ajovy. The health plan's determination is overturned. 

The patient is a girl who has been diagnosed with chronic migraine without aura. 
The provider's notes describe that the patient started to have headaches. They increased in severity and frequency until they had been occurring daily for 5-6 months prior to her first visit. There were no apparent triggers, and the headaches could occur at any time of day. The headaches were frontotemporal or involved her whole head (holocephalic). They ranged in severity from a 4/10 to 8/10, and lasted for several hours. Severe headaches were associated with photophobia, phonophobia, nausea and occasional vomiting. They became worse with routine physical activity and were not relieved by sleep. She started nortriptyline which she tolerated well but had not resulted in improvement of her symptoms at a dose of 30 milligrams (mg) daily. She was using ibuprofen 400mg-600mg 3 times per week but stopped it as it did not appear to be helping. She had stopped playing lacrosse and had missed around 12 days of school due to headaches. She was seeing a counselor for anxiety. She slept for 6-7 hours per night. 
There was a strong maternal history of migraine (mother, maternal aunt and grandmother). Isabella's birth history, past medical history and developmental history were unremarkable. 

The Ajovy autoinjector 22mg/1.5 AUTO INJCT is medically necessary for this patient. She has frequent, debilitating migraines, which are severely affecting her schooling and overall quality of life. She has had well-documented trials of two different classes of prophylactic medications, including nortriptyline (a tricyclic antidepressant) and topiramate in the form of Trokendi (an anticonvulsant). She is still having 1-2 headaches per week. She had a good response to a trial of Ajovy, with reduction in both frequency and severity of headaches. Migraine is common in children and adolescents. The prevalence of migraine in children and adolescents is estimated at 7.7% in a systematic review of population-based studies. The prevalence of chronic migraine in adolescents (12-17 years of age) is estimated at 1.7%. Frequent migraine and chronic migraine have been shown to cause significant adverse impact on quality of life of children and adolescents.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary
Pharmacy/Prescription Drugs

Diagnosis: Endometriosis
Treatment: Lupron Depot
The insurer denied Lupron Depot. The health plan's determination is upheld. 

The patient is a female who presented with dyspareunia and pelvic pain. She had a history of endometriosis. Pelvic ultrasound was normal. She had a history of Lupron Depot use over one year for treatment five years ago. She has taken combined oral contraceptives for many years. She declined pelvic floor physical therapy for treatment. She cannot take non-steroidal anti-inflammatory medication with her history of reflux disease. She attempted the contraceptive patch. There is no office visit to document effects from the patch. She would like to use Lupron Depot 11.25 milligrams (mg) for 6 months for treatment; however, this has been denied.

Lupron Depot is not medically necessary for this patient.
Lupron Depot is medically necessary with endometriosis (for a lifetime maximum of 12 months total) when the patient has had recurrence of symptoms and a bone mineral density is normal. Treatment beyond two treatments (total of 12 months) is considered unproven and not medically necessary. This patient has already had one full year of treatment with Lupron and no bone density test has been performed. Therefore, Lupron is not medically indicated. In addition, there is no documentation that the combined contraceptive patch was ineffective for treatment. Oral and depot medroxyprogesterone acetate has also not been attempted per the medical record. Finally, use of the levonorgestrel-releasing intrauterine system (Mirena) reduces pelvic pain associated with endometriosis and has not been documented as attempted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure. 
Treatment: Inpatient admission. 

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

The patient is a male with a past medical history significant for coronary artery disease, congestive heart failure, systolic dysfunction with EF (ejection fraction) 25%, status post AICD (automatic implantable cardioverter defibrillator), HTN (hypertension), diabetes, and dyslipidemia. He presented to the hospital with worsening dyspnea, chest pain on exertion, abdominal pain, nausea and vomiting. 

The patient was hemodynamically stable. His labs were significant for elevated creatinine, consistent with acute kidney injury, elevated troponin, consistent with acute myocardial injury, elevated lactate of 2.7 and elevated BNP (brain natriuretic peptide). Chest x-ray revealed right pleural effusion. Abdominal CT (computed tomography) revealed colitis with ischemic pattern, as well as small volume ascitis. 

The patient was admitted to inpatient level of care for management of colitis, CHF (congestive heart failure) exacerbation and ACS (acute coronary syndrome). He was seen in consultation by surgery, cardiology, and gastroenterology specialists. IV (intravenous) diuresis was initiated with monitoring of renal function, and medical therapy was adjusted given his AKI (acute kidney injury). Given his known history of three vessel coronary disease and no targets for revascularization, as well as poor viability on thallium scan, he was felt not to be a candidate for surgical or percutaneous revascularization and was managed medically. He improved clinically and was transitioned to oral diuretic. The patient was subsequently discharged with a plan for outpatient follow-up. 

Yes, the Inpatient admission was medically necessary. 

The patient presented with symptoms of acute CHF (congestive heart failure) exacerbation, chest pain on exertion with elevated troponin levels, consistent with acute myocardial injury, with known severe systolic dysfunction and CAD (coronary artery disease). In addition he had findings of ischemic colitis on CT (computed tomography) scan with elevated lactate level. His course was further complicated by acute kidney injury. This patient with multiple co-morbidities, who presented with CHF (congestive heart failure) exacerbation was appropriately treated with IV (intravenous) diuresis. He required close monitoring of his CHF (congestive heart failure) and renal function, given the underlying kidney disease. Given this presentation, acute CHF (congestive heart failure), as well as multiple risk factors, co-morbid conditions and known CAD (coronary artery disease), it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.