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

Diagnosis: Idiopathic Short Stature (ISS). 
Treatment: Nutropin. 

The insurer is denied coverage for Nutropin. 

The denial is upheld. 

This female patient has a history of diagnosis of idiopathic short stature (ISS). 

Classic GH deficiency. 
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity 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 SD [standard deviation(s)] below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year [yr(s)] more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low Insulin Like Growth Factor 1 (IGF1) or Insulin-like growth factor-binding protein 3, IGFBP3 or growth hormone (GH) stimulation testing with a peak GH less than 10ng/ml. 

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 

Idiopathic Short stature: 
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines  [4, [5, [6, [7, [8, [9]. FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means." 

The patient does not have a current pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 

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

The carrier's denial of coverage for the Nutropin is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pancreatic cyst.
Treatment: Topographic Genotyping (cpt 81479).
The insurer denied the Topographic Genotyping (cpt 81479).
The denial is overturned.

The patient is a female with a history of a pancreatic cyst that has enlarged to 3.3. cm (centimeters). FNA (fine needle aspiration) revealed a CEA (carcinoembryonic antigen) of 407. Cytology revealed debris and degenerated cells, and was indeterminate. Her provider requested topographic genotyping.

Yes, the health plan should cover the proposed topographic genotypic testing.
Arner et al concluded that the addition of DNA (deoxyribonucleic acid) molecular analysis alters the clinical management of pancreatic cystic lesions most often when CEA (carcinoembryonic antigen) levels are intermediate (45-800 ng/mL [nanograms per milliliter]) or when no CEA (carcinoembryonic antigen) concentration is available. Farrell et al concluded that clinical characteristic of patients in which DNA (deoxyribonucleic acid) abnormality testing has the greatest impact on patient outcomes.

The use of DNA (deoxyribonucleic acid) abnormality testing is supported in a carefully selected patient population limited to cysts with worrisome features. As this patient's cyst had worrisome features of being over 3 cm (centimeters) and having an elevated CEA (carcinoembryonic antigen), the health plan should cover the topographic genotypic testing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Conduction System Disease.

Treatment Current Procedural Terminology (CPT) code 75561, magnetic resonance imaging (MRI), a special kind of picture of the heart without and with contrast (dye).

The insurer denied coverage for Current Procedural Terminology (CPT) code 75561, magnetic resonance imaging (MRI), a special kind of picture of the heart without and with contrast (dye).

The denial is overturned.

This is an adult female with episodes of syncope and near syncope. Her past medical history was significant for multiple sclerosis, hypertension and psoriatic arthritis. Electrocardiogram (ECG) revealed normal sinus rhythm with right bundle branch block and left posterior fascicular block (LPFB); bifascicular block. Stress echocardiography revealed a normal left ventricular (LV) ejection fraction and no ischemia. An implantable loop recorder (ILR) was placed to correlate episodes of syncope with tachy or brady arrhythmia but was unrevealing. Based on significant conduction system disease on ECG and a history of syncope, a cardiac magnetic resonance imaging (MRI) scan was requested in order to rule out infiltrative myocardial disease. 

Conduction system disease is common in patients with sarcoidosis, amyloidosis and other infiltrative cardiomyopathies. The differential diagnosis for patients presenting with syncope of unknown origin and His-Purkinje conduction system disease includes cardiac amyloidosis, hemochromatosis and sarcoidosis. Multimodality imaging including cardiac MRI are critical in making an accurate diagnosis in such conditions.

This patient presented with evidence of His-Purkinje System (conduction system disease) on ECG and syncope. A previously implanted ILR failed to reveal an etiology for syncope linked to tachy or brady arrhythmia. Bundle branch block with syncope in an adult is unusual and may be the result of infiltrative cardiomyopathy. 

In conclusion, cardiac MRI is medically necessary to assess for infiltrative cardiomyopathy in this case. The health plan did not act reasonably, with sound medical judgement or in the best interest of the patient.

The insurer's denial of coverage for Current Procedural Terminology (CPT) code 75561, magnetic resonance imaging (MRI), a special kind of picture of the heart without and with contrast (dye) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis Vulgaris.

Treatment Humira Pen-Psoriasis/Uveitis Starter 80 milligrams/0.8 milliliter (mg/ml) and 40 mg/0.4 ml subcutaneous (SC) Pen-injector Kit (Pnkt).

The insurer denied coverage for Humira Pen-Psoriasis/Uveitis Starter 80 milligrams/0.8 milliliter (mg/ml) and 40 mg/0.4 ml subcutaneous (SC) Pen-injector Kit (Pnkt).

The denial is overturned.

The patient is an adult male with psoriasis vulgaris who has failed therapy with methotrexate, triamcinolone, betamethasone, clobetasol, and halobetasol. The patient is unable to stand for long periods of time to make ultraviolet (UV) light therapy mechanically feasible. The patient has failed treatment with oral methotrexate. The physician is requesting Humira as the next treatment option to control the patient's psoriasis.  

The patient has failed topical therapy and requires systemic therapy for control and management of her psoriasis diagnosis. Methotrexate and topical steroid therapy have been tried and proven unsatisfactory. Light therapy would be an option; however, the patient is not able to mechanically stand for the prolonged period of time required to administer therapy based on the submitted documentation. As such, Humira injections are a reasonable alternative which can be administered within the psoriasis care guidelines.  

This is supported by UpToDate "Biologic agents are important treatment options for moderate to severe plaque type psoriasis [86,117-120]. The available biologics for psoriasis have excellent short-term and long-term efficacy and favorable tolerability." Included in this group is Humira.

In this case, based on the provided documentation, Humira is medically more appropriate than the other options. As such, Humira is approved, and the decision is overturned in whole based on the current evidence-based medical literature. The requested service is medically necessary based on the provided medical records and the medical literature.  

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

The insurer's denial of coverage for Humira Pen-Psoriasis/Uveitis Starter 80 milligrams/ 0.8 milliliter (mg/ml) and 40 mg/0.4 ml subcutaneous (SC) Pen-injector Kit (Pnkt) is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath; chest pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with history of tobacco abuse. She presented to the ER (emergency room) with shortness of breath and chest pain.

A CXR (chest x-ray) showed a lung mass.  Her exam was normal for SpO2 (pulse oximetry) of 98%, normal temperature, and BP (blood pressure) of 166/88.  She was admitted to the hospital.  CT (computed tomography) scan confirmed a lung mass.  She underwent a biopsy, which confirmed lung cancer.  A small pneumothorax was encountered post procedure.  She was stable, and she was discharged

No, the Inpatient admission was not medically necessary.

The patient was clinically stable, not hypoxic and not unstable on presentation.  She was not hypotensive or in a hypertensive emergency. While she had a lung mass and pain, this did not require acute level care for management.  She could have been managed in an alternative level of care.  A CT (computed tomography) lung biopsy can be performed on an outpatient basis and does not need to be performed in an acute level setting.  This could have been done on an expedited outpatient basis.  Pneumothorax is a known complication of this procedure, and this dose not warrant the procedure being conducted in an inpatient setting.  Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Insulin Dependent Type II Diabetes
Treatment: Continuous Glucose Monitor, Pre-service
The insurer denied the Continuous Glucose Monitor, Pre-service.
The denial is overturned. 

This is a male with type II diabetes on multiple injections of insulin per day. He has been using a Freestyle Libre for more than two years. His glycated hemoglobin (A1C) is 7.8%. The request for continuous glucose monitoring is under review. The prior request was denied as the patient does not have type I diabetes. The attending physician is appealing this determination.

Yes, the proposed Freestyle Libre continuous glucose monitoring system is medically necessary.
The Freestyle Libre has been shown to be safe and effective in this clinical situation and superior to fingerstick testing. In 101 patients with type II diabetes on two or more injections per day, use of the Libre continuous glucose monitoring system significantly improved glycated hemoglobin (A1C) levels. The changes in glycated hemoglobin (HbA1c) were 0.82% versus 0.33% in the intervention group using the continuous glucose monitoring system and control group, respectively, and 68.6% of the patients in the intervention group using the continuous glucose monitoring system had their glycated hemoglobin (HbA1c) reduced by 0.5% compared with 30.2% in the control group, and 39.2% had their glycated hemoglobin (HbA1c) reduced by 1.0% versus 18.6% in the control group without an increased frequency of hypoglycemia [1]. This patient has uncontrolled type II diabetes on multiple insulin injections per day. He is currently stable on Freestyle Libre continuous glucose monitoring. Without the Freestyle Libre, he would be at risk of worsening hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the requested Freestyle Libre continuous glucose monitor is medically necessary for this patient.

The requested Freestyle Libre continuous glucose monitor is medically necessary and should not be denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay, infection
Treatment: D2750 (white glass with high gold content crown; Tooth #31) and D3330 (nerve treatment on molar tooth, Tooth #31)
The insurer denied the D2750 (white glass with high gold content crown; Tooth #31) and D3330 (nerve treatment on molar tooth, Tooth #31)
The denial is overturned.

The patient is a male requesting dental benefits for a root canal (D3330) and crown (2750) on tooth #31. X-rays and clinical consultation were performed. 

The health plan denied the claim because it does not cover root canal treatment for adults. The patient appealed the determination because he needed this treatment prior to knee surgery so that this tooth infection would not have an impact on his knee.

Yes, the proposed root canal (D3330) and crown (2750) on tooth #31 is medically necessary.
As evident on the x-ray, tooth #31 exhibits extensive decay on the distal aspect of the tooth. Root canal treatment and crown are the standard of care when there is extensive decay and the patient wants to save and restore the tooth.

A tooth with extensive decay would be very painful once the decay begins to affect the nerve, and the infection can potentially spread to other areas of the body. The treatment to remove the nerve would be necessary to get the patient out of pain and remove the infection. The second step would be to place a crown to restore form and function and to protect the tooth from fracturing in the future.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain

Treatment: Physical therapy, procedure code 97110

The insurer denied coverage for physical therapy, procedure code 97110.

The denial is overturned.

This is an adult female with chronic medical problems including diabetes mellitus, osteoarthritis, spinal stenosis, and lumbar facet arthritis. She has a history of hip and knee surgeries. Currently under review is the medical necessity of physical therapy (PT), procedure code 97110.

According to the clinical notes, the patient presented for evaluation and treatment of back pain. She has had PT for her hip and knee (past surgical history). To date, there have been only 5 PT for her back pain. The latter note, documents modest improvement, particularly for functional mobility and greater independence for community ambulation with a straight cane. This physician agrees with the physical therapist, regarding additional treatment in order to "decrease risk of falls, decreased back pain, improve quality of life and functional independence."   

Taken under consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based.  

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

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, PT procedure code 97110 is medically necessary.

The insurer's denial of coverage for physical therapy, procedure code 97110 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety/depression, dementia and claustrophobia
Treatment: Increase Social Day Care Program From 3 Days To 5 Days Per Week
The insurer denied Increase Social Day Care Program From 3 Days To 5 Days Per Week.
The denial is upheld.

The patient is a female who is requesting an increase in social day care program from 3 to 5 times per week. Additional services are requested to reduce anxiety and provide respite for caregivers.  Her diagnoses include anxiety/depression, dementia and claustrophobia.

UAS (Uniform Assessment System) evaluation completed notes the patient is home alone and reported feeling lonely.  Her daughter works 7 days a week, 7 AM - 5 PM.  She needs assistance with all ADLs (activities of daily living), except bed mobility and eating and receives CDPAS (consumer directed personal assistance service) 24 hours per week.

No, the requested Increase Social Day Care Program From 3 Days To 5 Days Per Week is not medically necessary.
The proposed treatment is not consistent with standard of care.

This patient has medical conditions including anxiety/depression.  She receives CDPAS (consumer directed personal assistance service) 24 hours per week and attends social day care 3 days per week.  Social Day Care is a comprehensive program that provides functionally impaired adults with services including socialization, monitoring and supervision, personal care, and nutrition.  An increase in social day care from 3 to 5 days a week is not appropriate and medically necessary for this patient that receives CDPAS 24 hours per week.  Additional social day care days would be duplicating services that already being provided with CDPAS.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This is a male patient with a history of heroin and cocaine abuse. He presented requesting detoxification.  The patient had symptoms of diarrhea, nausea, vomiting, muscle aches, joint aches, and fatigue.  

The patient's vital signs were as follows: temperature 36.6, pulse 85, respiratory rate 16, blood pressure 117/79, and oxygen saturation 99%.  His exam was unremarkable.  He had a Clinical Opiate Withdrawal Score (COWS) of eight.  The patient's electrocardiogram (EKG) was normal.  His white blood cell (WBC) count was 15.72, hemoglobin was 14.5, platelets were 351 and his electrolytes were normal.  Urine toxicology was positive for cocaine and opiates.  The patient's chest x-ray was normal.  

The patient was admitted.  His plan of care included methadone.  On day one, the patient's vital signs were stable (VSS).  Current management was continued.  Day two, the patient's vital signs were stable.  Clinical Opiate Withdrawal Score (COWS) was three.  Methadone was continued.  The patient's white blood cells (WBCs) normalized.  Day three, the patient was cleared for discharge.

No, the proposed treatment was not medically necessary.

This patient with a history of polysubstance use was admitted after requesting detoxification.   He had symptoms including diarrhea, nausea, vomiting and aches.  However, the patient was hemodynamically stable and afebrile.  He did not have an arrhythmia.  Labs were remarkable for positive urine toxicology for cocaine and opiates.  Electrolytes were normal.  There were no physical signs of severe withdrawal.  He did not have severe nausea and vomiting.  He was able to tolerate oral intake (PO).  He did not have comorbid conditions.  The patient was admitted with plan for Clinical Opiate Withdrawal Score (COWS) protocol and management with methadone.  He remained clinically stable during hospital stay without signs of severe withdrawal.  Ongoing Clinical Opiate Withdrawal Scores (COWS) were low.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease.
Treatment: Stelara 90 milligrams/milliliter subcutaneously, solution pre-filled syringe (SOSY), dosed every 5 weeks.
The insurer denied the Stelara 90 milligrams/milliliter subcutaneously, solution pre-filled syringe (SOSY), dosed every 5 weeks.
The denial is upheld.

The patient is a male who has a history of Crohn's disease. The patient also has a history of chronic kidney disease, elevated cholesterol, hypertension, diabetes and gout. He was diagnosed with Crohn's disease many years prior. The patient had undergone surgery for this condition in the past as well. He was started on Stelara approximately three years ago. His dosing was previously increased to every 6 weeks due to symptoms. The provider is now requesting the provision of Stelara every 5 weeks.

No, the proposed Stelara dosing every 5 weeks is not medically necessary.
The provision of Stelara at a frequency of every 5 weeks has inadequate literature support to show that it is more effective as the standard dosing of this medication (90 milligrams every 8 weeks).  This dosing has not been shown to have a positive effect on health care outcomes.

Jauregui-Amezaga et al., Danese et al. and Simon et al. all note the use of Stelara in the management of Crohn's disease. However, there is no notation or support of use every 4 weeks for maintenance dosing.

Since dosing Stelara every 5 weeks has not been shown to have a positive effect on health care outcomes more than standard dosing of this medication, the plan did act reasonably.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: seizure

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This female patient has a history of polycystic ovary syndrome (PCOS) and morbid obesity.

The patient was admitted to the medical floor with working diagnosis of seizure.  It was reported that neurology was consulted and there was no need for antiepileptics.  An magnetic resonance imaging (MRI) was scheduled for the next day.  The patient was treated with Keppra and Ativan.  The patient would be recommended for an electroencephalogram (EEG) as an outpatient.  MRI of the brain completed and it revealed mild enlargement of the temporal horn of the right lateral ventricle and mild changes of mesial temporal sclerosis.  Follow-up neurology note reported the patient had no active complaints.  Imaging was reviewed.  The patient was recommended for EEG as an outpatient upon discharge.  The discharge summary reported the patient had no complaints of pain and was in no apparent distress at the time of discharge.  The patient was discharged home in stable condition.

The health plan did act reasonably with sound medical judgment, and 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: Breast Cancer. 
Treatment: Verzenio 100mg tablet. 

The insurer denied the Verzenio 100mg tablet. 
The denial is upheld. 

The patient is an adult female with breast cancer.  She was diagnosed with metastatic disease several years ago.  She was treated with TCH-P (Taxotere + Carboplatin + Herceptin + Perjeta) then hormonal therapy surgery.  Her physician started Verzenio for CNS (central nervous system) protection. 

No, the Verzenio 100mg tablet is not medically necessary. 

There is no current evidence to support the use of Verzenio to treat metastatic HER2 (human epidermal growth factor receptor 2)+ breast cancer.  The NCCN (National Comprehensive Cancer Network) does not support Verzenio as therapy for HER2 (human epidermal growth factor receptor 2)+ breast cancer.  While small phase II trials have been conducted with this agent in HER2 (human epidermal growth factor receptor 2)+ disease, these have not led to support of the use of this agent in HER2 (human epidermal growth factor receptor 2)+ disease. 

The patient's physician cites the MONARCH study and the use of this data for brain protection.  The MONARCH study was an adjuvant study and did not include HER2 (human epidermal growth factor receptor 2)+ disease.  There is no evidence that Verzenio will offer CNS (central nervous system) protection in HER2 (human epidermal growth factor receptor 2)+ disease.  Therefore, given the above, the Verzenio is not medically necessary.