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

Diagnosis: Breast Cancer
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female with known metastatic breast cancer of the brain. She had a recent pulmonary embolism and was on anticoagulation with a history of retroperitoneal bleed and is on Xarelto. The patient was sent to urgent care for altered mental status from a skilled facility. A magnetic resonance image (MRI) of the brain showed new leptomeningeal enhancement and progression of the brain metastasis. The patient was admitted. She had multiple studies performed including echocardiogram, electrocardiogram (EKG), and lower extremity ultrasound. 

On day # (number) 4, a brain computed tomography was performed that was unchanged. On day #5, the patient underwent lumbar puncture (LP). The LP was negative. Neurosurgery declined any interventions. It was noted that the patient would need ten to 14 days of acute stay to be able to be placed in acute rehabilitation. 

The patient remained in the hospital with inability to ambulate and blurry vision. On day #14, the patient was noted to have been exposed to COVID (Coronavirus 2019). She was not participating with physical therapy. On day #20, the patient was discharged to rehabilitation.

The proposed inpatient hospital admission was not medically necessary.

This patient was essentially admitted and kept in the hospital to be able to qualify for acute rehab per the notes. There were no interventions or therapy given during this hospitalization. Outside of a protracted evaluation of her progressive brain metastasis from day of admission through day #5, there was no significant medical interventions performed. This hospitalization was custodial in nature and was not necessary at an acute level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth hormone deficiency

Treatment: Omnitrope Solution Cartridge (SOCT) 10 milligrams (MG)/ 1.5 milliliters (ML)

The insurer denied coverage for Omnitrope SOCT 10MG/1.5ML

The denial is overturned

This is a young male diagnosed with short stature. As reported, he is taking Omnitrope 1 mg daily. His mother states he did not miss any doses of medication. He has been taking Omnitrope for over 3 years. His Growth Hormone (GH) stimulation test pre-treatment with clonidine and arginine peaked at 9.9. His magnetic resonance imaging (MRI) was normal. His recent bone age revealed a difference of a few months less than chronological age (CA). His height velocity on therapy is reported to be 7.1 centimeters/years (cm/yr). Recent notes show he is at tanner 1. Previous insulin-like growth factor 1 (IGF1) was 65 and insulin-like growth factor-binding protein 3 (IGFBP3) was 1793. His recent weight was 30.6 kilograms (kg). His recent height was 137.3 cm [-1.46 standard deviation score (SDS)].

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 standard deviations (SD) 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 yr 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 IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10 nanograms (ng)/ ml.
		
The patient has growth hormone deficiency based on prior approvals. The patient is continuing therapy. The documentation provided reports that the patient did not miss any doses of the medication. The patient's height velocity on treatment is excellent. The patient has open growth plates. Continuation of growth hormone is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The references provided are the most current/relevant to the case.

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

The medical necessity for Omnitrope SOCT 10MG/1.5ML services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GERD (gastroesophageal reflux disease)
Treatment: EGD (esophagogastroduodenoscopy)
The insurer denied the EGD.
The denial is upheld.

The patient is an adult male with GERD (gastroesophageal reflux disease) and possible Barrett's esophagus diagnosed 3 years ago (pathology not provided). The EGD (esophagogastroduodenoscopy) at that time was negative for Barrett's esophagus. The patient underwent a surveillance EGD. The EGD test was not medically necessary.

For surveillance of Barrett's esophagus, EGD is required every three to five years, based on American College of Gastroenterology guidelines. However, this patient did not have Barrett's esophagus based on pathology from EGD 3 years ago. There were no other reasons/indications for the EGD listed in the documentation.

Therefore, given the above, the EGD test was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease
Treatment: EGD (esophagogastroduodenoscopy)
The insurer denied the EGD.
The denial is upheld.

The patient is an adult male. Per a clinic visit, the patient had occasional abdominal cramps. An EGD (esophagogastroduodenoscopy) was performed for indication of GERD (gastroesophageal reflux disease), hiatal hernia.

Per the denial letter, EGD biopsy (procedure code 43239) was denied coverage by the health plan due to the listed indication being heartburn without documentation of trial of medical therapy for 8 weeks prior to endoscopic evaluation.

The EGD was not medically necessary.

The procedure note indication is GERD, the clinic note also mentioned abdominal cramps. There is no evidence of trial of acid suppression, no alarming features such as iron deficiency anemia, dysphagia, or weight loss documented.

Per the American College of Gastroenterology (ACG) Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease in 2022,

"1) For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric PPIs [proton pump inhibitors] once daily before a meal (strong recommendation, moderate level of evidence). 2) We recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-week empiric trial of PPIs (conditional recommendation, low level of evidence). 3) We recommend diagnostic endoscopy, ideally after PPIs are stopped for 24 weeks, in patients whose classic GERD symptoms do not respond adequately to an 8-week empiric trial of PPIs or whose symptoms return when PPIs are discontinued (strong recommendation, low level of evidence)."

The patient is not documented to have been put on 8-week empiric trial of PPIs prior to proceeding with upper endoscopy. Thus, the procedure was not medically necessary per the current clinical guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90MG/ML (milligrams per milliliter) SC (subcutaneous) SOSY (Solution Prefilled Syringe)
The insurer denied the Stelara 90MG/ML SC SOSY.
The denial is overturned.

The patient is an adult male with Crohn's disease (CD) colitis with deep linear ulcers in the transverse colon. He was first diagnosed last year. He failed treatment with Entyvio. During a colonoscopy earlier this year the scope had to be withdrawn due to severe colitis, deep linear ulcers found in the transverse colon. The patient's provider is requesting initiation of Stelara every 8 weeks due to the fact that the patient 
received Stelara during a recent hospitalization, and due to the fact that he cannot switch from a biologic due to development of antibodies and resistance. The patient had significant improvement on the inpatient Stelara dosing.

Since the denial, the patient was admitted several times for CD flares. Currently the patient is in active disease with blood in stools 4-5 episodes, and he is losing weight again.

The health plan's reason for denial of coverage per the denial, is that there is lack of prior utilization of other preferred agents, Reflexis, Inflectra or Avsola, Humira, and Cimzia. The denial is being appealed.

The requested Stelara is medically necessary.

Per the American Gastroenterological Association (AGA) Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn's Disease, "Recommendation 1C. In adult outpatients with moderate to severe CD, the AGA recommends the use of ustekinumab over no treatment for the induction and maintenance of remission. (Strong recommendation, moderate certainty evidence)" [1]

"The Panel recommends treating adult outpatients with moderate to severe luminal CD with infliximab, adalimumab, certolizumab pegol, vedolizumab, OR ustekinumab over no treatment for the induction and maintenance of remission." [1]

The AGA recommended using any agent as a first line and there is no clinical standard or evidence that any agent should be tried prior to the use of ustekinumab, thus the requirement by the health plan to utilize other agents is not based on the current standard of care that is supported by the current medical evidence and endorsed by the major gastroenterology societies. Therefore, the requested Stelara is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion 
Treatment: Braces and monthly visit
The insurer denied coverage for braces and monthly visit.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment notes as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite in addition to skeletal Class III, and maxillary and mandibular crowding. The orthodontist has completed Handicapping Labio-Lingual Deviation (HLD) Index Report as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage or orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 16 points by internal reviewers when 26 points are required for approval. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The medical necessity for braces and monthly visit is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Continued PHP (partial hospitalization program) Substance Use Treatment (0912)
The insurer denied the continued PHP substance use treatment (0912).
The denial is upheld.

The patient is an adult male. Under consideration is treatment at PHP (partial hospitalization program) level of care for five sessions. The original admission had been due to alcohol and cocaine use. The final adverse determination indicates that as 
of the time in question, ASAM (American Society of Addiction Medicine) Criteria were not met for continued PHP. Medical records indicate the patient to have been admitted with 32 days of sobriety from cocaine and alcohol. At the time of intake, mental status exam was normal with PHQ (patient health questionnaire)-9 score of 3. Medical evaluation was also normal, with all vital signs within acceptable parameters. Prior to the time in question, the patient's mood was euthymic with normal mental status findings. Some thoughts and cravings have been present as well as fluctuating but minimal anxiety. Insight and motivation remain superficial and external with some struggles in asking for help. On the initial date in question, the patient participated actively and in an engaged manner in groups. No impairment in interaction with peers or staff was documented. A UDT (urine drug test) was negative. A note revealed some low mood with a great deal of thought about a friend with similar difficulties. Progress is noted to have been inadequate, but the patient is noted to have committed to changing his behaviors. Some anxiety and withdrawal are present.

The continued PHP substance use treatment (0912) was not medically necessary.

The patient was first admitted to PHP the month prior to the dates in question. Under consideration was continuation of PHP. The patient did not continue to demonstrate interpersonal and/or personal skills deficits through interactions with others, he was not demonstrating difficulty managing triggers or urges, he was connected to a social network supportive of recovery goals, he had established a therapeutic alliance with at least one professional helper. Under LOCADTR (Level of Care for Alcohol and Drug Treatment Referral), he did not meet medical necessity criteria for continued stay at outpatient day rehabilitation (the equivalent of ASAM Level 2.5 PHP).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fertility preservation
Treatment: Additional In Vitro Fertilization (IVF) Cycle With Embryo Freezing and Biopsy
The insurer denied additional IVF cycle with embryo freezing and biopsy.
The denial is upheld.

The patient is an adult female in a same-sex relationship. She presented interested in fertility preservation. She does not have a diagnosis of infertility. The patient underwent in vitro fertilization (IVF) using donor sperm. She has 5 frozen embryos. However, she tested positive for congenital adrenal hyperplasia due to 21-hydroxylase deficiency, and she is a possible carrier of mitochondrial DNA (deoxyribose nucleic acid) depletion syndrome 4A and 4B and other POLG (deoxyribose nucleic acid polymerase gamma, catalytic subunit) related disorders. The patient is requesting coverage for a second IVF cycle, as the donor that she has used previously was not tested for those two conditions.

The additional IVF cycle with embryo freezing and biopsy was not medically necessary.

Specifically, the patient does not have a diagnosis of infertility, as she has no exposure to sperm. In order to be diagnosed with infertility, this patient needs to fail six cycles of intrauterine insemination. The patient is requesting coverage for IVF for fertility preservation. This patient may not need to preserve her fertility; she may try conceiving whenever she is ready to. The patient is not undergoing any treatment that will impair her ability to get pregnant in the future, such as surgical removal of her ovaries, radiation therapy, or chemotherapy.

In addition, the patient had already undergone a cycle of IVF for fertility preservation. She has five embryos frozen. While she is a carrier of congenital adrenal hyperplasia due to 21-hydroxylase deficiency and she is a possible carrier of mitochondrial DNA depletion syndrome 4A and 4B and other POLG related disorders, the probability that the sperm donor used in the prior cycle is a carrier of these two conditions is extremely low. In the absence of an ethnic background, ACOG (American College of Obstetricians and Gynecologists) recommends testing only for cystic fibrosis and spinal muscular atrophy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This adult presented to the hospital complaining of intermittent chest pain radiating to the left arm for three weeks. Pain was brought on by activity and relieved with rest. Past medical history was significant for hyperthyroidism, hyperlipidemia, and asthma. Upon arrival to the emergency department, the patient was hypertensive with a blood pressure of 192/84 and her pulse was 84. Physical examination revealed no abnormalities. A 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm with ST (interval on an ECG) depressions in the inferior leads and T wave (interval on an ECG) inversions in leads V2, V3 and V4 (chest leads). Serum blood testing revealed an increased D-dimer level (1400) and no elevation in troponin. The patient was admitted to the hospital for observation and treatment. An echocardiogram revealed a preserved left ventricular ejection fraction without wall motion abnormalities. Myocardial perfusion testing was positive for inferior wall ischemia. The patient was treated medically and released with plans for outpatient cardiac catheterization. 

This patient presented with chest pain exacerbated with activity and poorly controlled hypertension. Her pretest probability of coronary artery disease is intermediate. Utilizing the HEART (History, ECG, Age, Risk factors, and Troponin) score, she was considered high risk. Risk assessment of patients presenting with chest pain and no significant ST changes on an ECG was reviewed by Hedayati, et al. Using the HEART score risk stratification schema, this patient would have an elevated risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary. 

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

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Traumatic Brain Injury, Primary lateral sclerosis; weakness in extremities.
Treatment:  Durable Medical Equipment (10861 x1, E2377 x1, E2313 x1, E2323 x1, El 007 x1, E2300 x1, E2621 x1, E0955 x1, E1012 x1, K0040 x1, E2311 x1, K0108 x1, E1028 x4, E0956 x4, E2607 x1).

The insurer denied the Durable Medical Equipment (10861 x1, E2377 x1, E2313 x1, E2323 x1, El 007 x1, E2300 x1, E2621 x1, E0955 x1, E1012 x1, K0040 x1, E2311 x1, K0108 x1, E1028 x4, E0956 x4, E2607 x1).  The denial is upheld.

The records indicate that the patient is an adult female with a history of traumatic brain injury due to motor vehicle accident twenty years ago with chronic left sided weakness. More recently the patient was diagnosed with primary lateral sclerosis. There is question whether this has converted to an amyotrophic lateral sclerosis. Functionally, there has been progressive decline. She has been getting weaker. There has been intermittent spasticity in the legs. There has been poor balance. She has had falls, especially when she is tired but also due to sudden loss of consciousness. She lives with her mother who is her primary caregiver. She has a supportive significant other. She lives in a home with two entrances that do not require step negotiation. Her bedroom is on the second floor. On the mobility evaluation, the patient was found to be able to stand pivot transfer. She was unable to functionally ambulate despite use of a gait assistive device or to functionally propel a manual wheelchair. A power wheelchair was advised.

The health plan denied coverage of the service under review, indicating that the service cannot be approved due to insufficient information, including lack of information indicating that the patient's home is accessible to the requested item and that the patient's weight was within the capacity of the item.

The proposed treatment was not medically necessary.

Per the standard of care, when evaluating medical necessity for durable medical equipment such as the power wheelchair in question, consideration is taken for factors such as utility as well as safety. While the power wheelchair may provide some benefit to the patient in this case, as reported in the provided clinical records, the patient regularly loses consciousness for unexplained reasons. Losing consciousness while operating a power wheelchair could cause very serious bodily harm to the patient or to others. Therefore, standard of care would not support the use of this power wheelchair for the patient given the present circumstances. In summary, the records indicate that the patient regularly loses consciousness for unexplained reasons. Given this clinical history, she would not be expected to be a safe operator of a power wheelchair. A power wheelchair with the requested accessories is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Necrotizing fasciitis 
Treatment: Skilled Nursing Facility Subacute Rehabilitation Level 2 Services
The insurer denied Skilled Nursing Facility Subacute Rehabilitation Level 2 Services.
The health plan's determination is upheld. 

This is a female with necrotizing fasciitis and diabetes who was admitted to skilled nursing facility for wound care and rehabilitation. She was maximum assist for transfers, ambulation and activities of daily living.

Skilled Nursing Facility Subacute Rehabilitation Level 2 Services is not medically necessary for this patient. The patient has improved significantly and is currently modified independent with bed mobility, supervision transfers, and ambulating 200 feet with a RW (rolling walker). The activities of daily living (ADL) are CG (contact guard)/supervision level. Stairs require CG for 8 steps. Dressing changes are required for the thigh wounds. As of the date in question a lower level of care would be appropriate for this patient.