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

Reviewer #3:

Diagnosis: Pediatric migraine headaches

Treatment: Nurtec ODT (oral disintegrating tablet) 75 mg (milligram) TAB (tablet) RAPDIS 8.0 for 30 days

The insurer denied coverage for Nurtec ODT 75 mg TAB RAPDIS 8.0 for 30 days

The denial is upheld 

The patient is a young teenager with request for Nurtec. The final determination notice indicated that Nurtec was denied for pediatric use. 

The patient was seen for chronic intractable migraines. She stated that headaches were daily. Past care was listed as intravenous (IV) infusions, medications, and occipital nerve blocks. The patient reported that Nurtec made headaches worse after a few minutes of benefit. The patient also preferred non-orally dispersible tablets over ODT as they made her more likely to vomit. Treatment plan included Nurtec ODT.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes.

Nurtec ODT does not have final approval from the appropriate regulatory bodies for this diagnosis in pediatric patients.

This patient is not a good candidate for Nurtec ODT.

Nurtec ODT is not the best available treatment for this patient at this time.

Adverse risks are increased over standard treatment.

Nurtec is approved by the Food and Drug Administration (FDA) in adults for the treatment of migraine and preventive treatment of episodic migraine. The safety and effectiveness in pediatrics has not been established. 

This case involves a pediatric patient who stated that Nurtec made headaches worse and was more likely to make her vomit. The recommendation for ongoing use would not be supported given lack of effectiveness. Therefore, the prior determination is upheld. 

In summary, the denial of Nurtec ODT 75 mg TAB RAPDIS 8.0 for 30 days should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

Diagnosis: Pediatric migraine headaches

Treatment: Nurtec ODT (oral disintegrating tablet) 75 mg (milligram) TAB (tablet) RAPDIS 8.0 for 30 days

The insurer denied coverage for Nurtec ODT 75 mg TAB RAPDIS 8.0 for 30 days

The denial is overturned

The patient is a young teenager with a diagnosis of chronic intractable migraine without aura, anxiety, and somatization disorder. The patient has daily headaches and reports nothing has helped. Nurtec helps for a few minutes, and then the patient feels worse. The patient has tried and failed occipital nerve block, Cambia, Compazine, Aimovig, propranolol, venlafaxine, ibuprofen, Zomig, Zofran, Benadryl, Sudafed, Sumatriptan, Maxalt cannabidiol gummies, naratriptan, naproxen, Topamax, amitriptyline, Zyprexa, prednisone. Current medications include Aimovig, propranolol, and venlafaxine.

This patient is an adolescent. Nurtec has been studied in adults and has been recommended in adolescents pending completion of prospective clinical trials. 

The Pediatric & Adolescent Headache special interest group of the American Headache Society provided expert opinion (class IV evidence) on the use of anti- 
Calcitonin Gene-Related Peptide (CGRP) Receptor monoclonal antibodies (mAbs) in children and adolescents. According to recommendations, "Given the relative unknowns, until studies in children and adolescents are completed, anti-CGRP mAbs should be considered primarily for post-pubertal adolescents experiencing relatively frequent migraine (8 headache days per month) with moderate or severe migraine-related disability [as measured by Pediatric Migraine Disability Assessment (PedMIDAS) or other validated instrument]."

Conclusions supported CGRP monoclonal antibody treatment as beneficial to a proportion of adolescents with chronic refractory headache disorders.

There is a lack of clinical studies on acute and preventative therapies in pediatric migraine, and no drugs are exclusively indicated for migraine treatment in this age group. Therefore, it is important to follow treatment recommendations by experts in the field of pediatric migraine.

The patient has tried and failed other abortive medications from multiple classes that are currently available for her age group. Due to the chronic, refractory nature of her symptoms and lack of response to other treatments, Nurtec ODT is the best available treatment at this time.     

Based on the above studies, Nurtec ODT is safe and actually has fewer adverse risks compared to other standard treatments/services.     

Nurtec ODT is likely to be more beneficial than any of the standard treatments for this patient who has tried and failed multiple classes of both abortive and preventative medications.                                                    

In summary, the denial of Nurtec ODT 75 mg TAB RAPDIS 8.0 for 30 days should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature
Treatment: Genotropin
The insurer denied the Genotropin.
The denial is upheld.

The patient is a young school aged male followed by his pediatric endocrinologist for short stature. He was born at term, five pounds, four ounces, 17 inches long, small for gestational age (SGA) but caught up by one to three months old. The patient's height used to track close to the fifth to tenth percentile from two to six years old. This patient has been tracking between the tenth to the 25th percentile from six years old to present. The patient's height was 119.7 centimeters at seven years and seven months. The patient's height was 117 centimeters at seven years and one month.

Bone age was read as closest to the eight-year-old standard at chronological age of seven years and six months. Predicted adult height is 65.2 inches. Midparental height is 68.5 inches. 

Insulin-like growth factor binding protein three (IGFBP-3) was normal at 2303 micrograms per liter (ug/L). Insulin-like growth factor one (IGF-1) was low at 104 nanograms per milliliter (ng/mL) (normal 108-307). The patient underwent growth hormone (GH) stimulation testing. This showed normal growth hormone (GH) peak of 17.4 nanograms per milliliter (ng/mL) after Arginine and Clonidine.

The patient's endocrinologist would like to initiate growth hormone (GH) therapy for idiopathic short stature (ISS). Coverage was denied for not meeting criteria for idiopathic short stature.

An appeal letter from the treating physician suggested that idiopathic short stature is one of the Food and Drug Administration (FDA)-approved indications for growth hormone therapy, and that patient's predicated adult height of 64 to 65 inches is shorter than his midparental height of 68.5 inches.

The proposed treatment is not medically necessary.

The use of growth hormone therapy is considered medically necessary if the criteria for growth hormone therapy in idiopathic short stature are met.  

The Food and Drug Administration approved the use of growth hormone for the treatment of idiopathic short stature as defined by height standard deviation score (SDS) less than or equal to -2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed, and whose expected adult height is less than 63 inches (160 centimeters) for boys and 59 inches (150 centimeters) for girls. 

Based on the clinical information provided, the patient's clinical characteristics do not meet the criteria for treatment under the Food and Drug Administration approved indication of idiopathic short stature, as the patient's pre-treatment height is not more than 2.25 standard deviations (SDS) below the mean for age/sex. 

As such, the drug is not being requested for a medically accepted indication as supported by current medical literature and any applicable diagnostic/treatment guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and Abnormal Heart Rhythm
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with a past medical history of hypertension, hyperlipidemia, diabetes, and paroxysmal supraventricular tachycardia.  She presented to the emergency department for evaluation of palpitations and dizziness. On arrival to the emergency department, the patient was afebrile, heart rate was 179 beats per minute (bpm), respiratory rate was 20, and oxygen saturation (SPO2) was 99%(percent) on room air.  

On exam, the patient was noted to have lower extremity edema. Initial labs were notable for a sodium of 132, creatinine of 1.47, and glucose of 604. Her troponin was elevated.  Initial electrocardiogram (EKG) showed supraventricular tachycardia with a heart rate of 169 beats per minute (BPM). The patient was hydrated with intravenous fluids, and she received intravenous adenosine and oral aspirin. For hyperglycemia, she was treated with intravenous insulin. Upon administration of adenosine, the patient converted to normal sinus rhythm.  

The patient was admitted to the inpatient unit for further care. She was evaluated by cardiology and was started on metoprolol 25 milligrams twice daily. A transthoracic echocardiogram was obtained which demonstrated normal biventricular function without significant valvular abnormalities. Endocrinology was also consulted, and they recommended initiation of insulin therapy. The patient remained in normal sinus rhythm and was ultimately discharged with outpatient follow-up.

The proposed inpatient hospital admission was not medically necessary.

This patient presented to the emergency department with palpitations and was found to have supraventricular tachycardia.  She was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. After administration of adenosine, she converted to normal sinus rhythm and there was no further recurrence of her arrhythmia. There was no evidence of acute ischemia, acute heart failure, or sustained ventricular arrhythmias. Her echocardiogram did not demonstrate any significant findings. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip pain
Treatment: Hospital admission
The insurer denied the hospital admission.
The determination is overturned.

The patient has a history of a right slipped capital femoral epiphysis who presented with left hip pain and was found to have a left slipped capital femoral epiphysis. He was admitted to the hospital and underwent in-situ pinning of the left capital femoral epiphysis. At issue is whether an inpatient level of care is medically necessary.
An inpatient stay is medically necessary. It was necessary for the patient to limit his mobility from the time the diagnosis was made until the procedure had been performed. In some cases, this can be accomplished with crutch-walking, but in some circumstances it may require bedrest or the use of a wheelchair. Particularly, with the patient having recently had surgery on the opposite hip, it is essential to be sure that the patient is able to ambulate safely prior to discharge. Medicare considers this procedure (current procedural terminology (CPT) code 27176) to be an "inpatient only" procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope with LBBB (left bundle branch block)
Treatment: Inpatient Admission 
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult female. She was hospitalized from for syncope with LBBB (left bundle branch block). She was found unresponsive in the bathroom after having smoked crack cocaine. Her past medical history is remarkable for hypertension, asthma, bipolar disorder, major depressive disorder, ex tobacco abuse, crack cocaine abuse and past heavy alcohol abuse. Her outpatient medications include Buspar, Prozac and Strattera.

In the ED (emergency department), the patient's blood pressure was initially elevated to 169/111. O2 (oxygen) saturation was 95%. Rhythm was sinus at 87. Chest film and head CT (computed tomography) showed nothing acute. Troponin was marginally elevated at 0.041. LVEF (left ventricle ejection fraction) was 60-65% by echocardiography. Hypertension was treated with low-dose beta-blocker, metoprolol. The patient had no complaints and was discharged to home and referred for drug detox and Cardiology follow-up. This is an appeal of the denied claim of the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

The Inpatient Hospital Admission was not medically necessary.

Based on the peer-reviewed medical literature and the MCG (Milliman Care Guidelines) guidelines for Syncope, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, pericardial tamponade, syncope causing injury requiring hospitalization, cardiac arrhythmias of immediate concern, structural cardiac disorder like severe aortic stenosis or suspected as cause that requires immediate correction, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding or clinical condition judged not to be within scope of observation care. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care she received for uncomplicated syncope from a drug OD (overdose), stable LBBB (left bundle branch block) and nondiagnostic troponin elevation for NSTEMI (non-ST-elevation myocardial infarction) like in this case, is routinely provided safely and effectively at a lower level of care, such as at the Observation LOC (level of care).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation, Acute Bronchitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient has a history of morbid obesity, asthma, anxiety, and post-traumatic stress disorder (PTSD). The patient presented to the emergency department (ED) with complaints of dyspnea for 1 day. Also, reported were cough, hoarseness of voice and some chest pain for months. The patient had coronavirus and had symptoms.

The patient was seen in the ED for dyspnea and wheezing and was released home on oral steroids. The patient did not feel better and came back to ED. At presentation, the vital signs were temperature 98.6 degrees Fahrenheit, heart rate 80, respirations 19, and blood pressure 128/73 mm Hg (millimeters of mercury). Oxygen saturation was 97% (percent) on room air. The patient was alert and oriented with no acute distress. There was no jugular venous distention. Lung sounds demonstrated some wheezing localized to the throat area. The patient also had some bronchospastic cough. White Blood Cells were 7.6, electrolytes were normal. There was no acute pathology on the chest x-ray.  The patient was admitted for asthma exacerbation, acute bronchitis and morbid obesity.

The patient was seen by Pulmonary who recommended steroids and bronchodilators. Also recommended was Ear, Nose & Throat (ENT) evaluation as the patient's symptoms were mostly over the throat. The patient was evaluated by ENT due to hoarseness of voice. The patient remained stable after admission. The patient was awake, alert, in no acute distress, not hypoxic and able to tolerate food and fluids. Pulmonary function tests were normal.

ENT completed Laryngoscopy that revealed an immobile left vocal cord with incomplete closure. Speech & Language Pathology saw the patient and cleared the patient for oral thin liquids and a regular diet. This patient remained stable after admission and was not hypoxic. She was stable for discharge after a period under observation.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) - 24 Hours per Day (Live-In). 

The insurer denied Consumer Directed Personal Assistance Services (CDPAS) - 24 Hours per Day (Live-In). The health plan's determination is overturned. 

The patient is a male with past medical history of dementia, multiple myeloma, hypertension, urinary incontinence, bowel incontinence, gastroesophageal reflux disease (GERD), and osteoarthritis, who had been assigned Consumer Directed Personal Assistance Services (CDPAS).

Consumer Directed Personal Assistance Services (CDPAS) - 24 Hours per Day (Live-In) are medically necessary for this patient.

There is documentation from the patient's neurologist as well as the plan's own assessment documenting the patient's functional and cognitive decline. The plan's own assessment indicated the patient needed supervision with walking and locomotion as well as limited assistance with dressing lower body, transfer toilet, and toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time, and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. Because the patient has 24-hour care needs the plan inappropriately utilized tasking tool to calculate CDPAS services. The plan incorrectly assumed the patient had informal support outside of the currently assigned CDPAS services. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS 24 hours/day (live-in) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic arm weakness
Treatment: L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
The insurer denied coverage for L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
The denial is upheld

This case involves an adult male with a request for the L8702 prosthetic to address spasticity following stroke. The patient was seen for a follow-up and identified a goal of returning to work. There was ongoing spasticity in the left hand. Splinting and range of motion had been ineffective at restoring adequate function to the left upper extremity. A recommendation was made for custom myoelectric orthosis.  

Custom myoelectric orthosis was denied as it was considered experimental or investigational under the patient's health plan.

In an appeal, the provider requested approval for custom myoelectric orthosis. The device was intended to address the patient's upper extremity weakness. Multiple journal articles were cited in support of the treatment for the patient's clinical presentation. The patient had tried and failed occupational therapy, physical therapy, static bracing, electrical stimulation, and Botox injections.  

Per the cited references, myoelectric control systems have been utilized in studies to support patients with neuromuscular conditions. Some wearable robotic exoskeletons have been designed for rehabilitation and assistance in areas to be utilized in physical therapy in clinical environments, or to provide assistance during activities of daily living. The results suggest that a therapeutic approach integrating myoelectric bracing yields highly comparable outcomes to those derived from repetitive, task-specific practice-only. Myoelectric bracing could be used as alternative for labor-intensive upper extremity training due to its equivalent efficacy to hands-on manual therapy with moderately impaired stroke survivors. In this case, the patient was status post stroke. The provider recommended myoelectric control system. While literature notes that the treatment has been utilized for the management of stroke symptoms, literature does not support that the requested service is likely to be more beneficial than standard treatments/procedures for the patient. There is a lack of head-to-head studies to support that the treatment is more effective than standard treatments. 

In summary, the denial of L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated is upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.