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

Diagnosis:  Abnormal Papanicolaou Smear of Cervix - Low-Grade Squamous Intraepithelial Lesion

Treatment:  Genetic Testing for Trisomy and Microdeletions

The insurer denied the Genetic Testing for Trisomy and Microdeletions.  The denial was upheld. 

This is a female patient pregnant woman with a singleton pregnancy who underwent cell free DNA testing.  The patient has no history of any chromosomal anomaly.  There are no reports of an abnormal ultrasound.

According to the American College of Obstetricians and Gynecologists (ACOG), indications for considering the use of Cell Free Fetal DNA:

	- Maternal age 35 years or older at delivery 
	- Fetal ultrasonographic findings indicating an increased risk of aneuploidy 
	- History of a prior pregnancy with a trisomy 
	- Positive test result for aneuploidy, including first trimester, sequential, or integrated screen, or a quadruple screen. 
	- Parental balanced Robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21.

In a new recommendation issued in mid-2015, ACOG stated: "Given the performance of conventional screening methods, the limitations of cell-free DNA screening performance, and the limited data on cost-effectiveness in the low-risk obstetric population, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population".
 
The carrier's denial of coverage for genetic testing for trisomy and microdeletions for service is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-exertional left shoulder pain
Treatment: Inpatient admission

The proposed inpatient admission was not medically necessary.

The patient presented for evaluation of atypical chest pain. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. He had an abnormal stress test two months prior and he was referred for a cardiac catheterization, which revealed no coronary obstruction. There were no peri-procedural complications. There was no evidence of a bleeding or ischemic complication, peri-procedural myocardial infarction (MI), hemodynamic or electric instability. Thus the medical record does not support medical necessity for acute inpatient admission, and the services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis 
Treatment: Inpatient admission 
The inpatient admission was not medically necessary and this patient could have been managed at a lower level of care. 
The patient presented with biliary colic without evidence of an acute infection or sepsis. There was no fever, heart rate was normal, and there were no subjective findings of infection. 
During an acute attack of biliary colic, management is focused on pain control. Pain control can usually be achieved with nonsteroidal anti-inflammatory drugs (NSAIDs).  For patients with typical biliary colic and gallstones on imaging who are surgical candidates, elective cholecystectomy is recommended in order to prevent future attacks of biliary colic and complications of gallstone disease. For those patients whose biliary colic subsides while in the emergency department, follow-up for elective cholecystectomy should be arranged as emergency cholecystectomy is associated with a higher risk of complication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

At the time of admission, the patient was hemodynamically stable. Although the patient was reported to be in mild respiratory distress and was on BIPAP, the patient was speaking in full sentences. The patient's breathing had improved with emergency room care. By the next day, the patient's asthma exacerbation symptoms had improved. The wheezing had improved. The patient was hemodynamically stable. The patient was discharged home on that day.

Since the patient's symptoms started to improve with emergency room care and resolved within 24 hours of admission, the acute in-hospital stay was not medically necessary. Observation level of care is more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: RSV bronchiolitis, otitis media, and croup
 
Treatment: Admit and continue to treat with Tylenol, Amoxicillin, Decadron and nebulized albuterol.

The insurer denied the need for admission to the hospital and indicated that the child could have been safely discharged. The denial was upheld. 

The patient is a child with a fever and a cough for three days. The mother indicated that there had been some episodes of post tussive vomiting and there were sick contacts in the home.  On the day prior to the admission to the hospital, the child was diagnosed with bronchiolitis.  When the symptoms persisted, the mother brought the child to the Emergency Room (ER) for further evaluation.

In the ER, the child was noted to be breathing fast at a rate of 46.  The pulse oximeter reading was 89% and there were mild retraction noted.  The cough was described as being wet, and upon auscultation of the lungs, there were rhonchi audible.  There was also a diagnosis of otitis media based on the examination of the ears.  A test for the respiratory syncytial virus (RSV) virus was positive.  

The patient was treated appropriately in the Emergency Room (ER) for an acute episode of bronchiolitis, and when the child did improve following treatment, there was a note indicating that the child's clinical condition was stable for discharge to the home with a follow up with the pediatrician.  The medical record does not clearly indicate the reasoning for the decision to admit the child to the hospital.  If the child did improve with treatment in the ER and the child's pulse oximeter was in the normal range, then persistent tachypnea and an additional diagnosis of croup do not require admission to the hospital and the oral medications could have been prescribed for administration at home with appropriate follow up with the pediatrician.  The medical record does not support the need for admission to the hospital.
Appeal type: Medical necessity
Decision: Upheld

The patient presents for evaluation and treatment of teeth #29,30, and 31. In question is the medical necessity of the planned treatment of porcelain fused to gold crown for #29 and 30 (D2750), and two surface amalgam for tooth #31 (D2150).  

The health plan's determination is upheld. The requested procedures are not medically necessary. Full coverage crowns are not indicated for teeth #29 and 30, nor is there any indication for a two-surface amalgam on #31. Teeth #29 and 30 have non carious cervical lesions as well as recession. Currently neither the American Academy of Prosthodontics nor the Academy of Periodontology require that non carious cervical lesions be addressed with full coverage crowns.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who is seeking growth hormone (GH) treatment for the diagnosis of growth hormone deficiency (GHD). He was born after 36-37 weeks of gestation and his birth weight was 4 pounds (lbs) 11.3 ounces (oz). His mother's height is 5 feet (') 6 inches ('') and father's height is 5' 4''. He was seen in the pediatric endocrinology clinic  for evaluation of short stature. Prior to that, he had been evaluated at another facility for failure to thrive and his evaluation had shown normal growth factors, normal karyotype, normal microarray and short stature homeobox-containing (SHOX) gene testing. His bone age was read as 2 years delayed. His growth chart showed that his height was below the 3 percentile (%tile) and weight was less than (<) 1% until the age of 6 years but then he did not gain any weight between the ages of 6-7 years and his weight further dropped below the 1%tile. He was a picky eater and had a poor appetite. He was being followed by pediatric gastroenterology and was on cyproheptadine . His growth velocity was calculated as 5.1 centimeters (cm) per year in the preceding years.
The health plan's determination is upheld. Genotropin is not medically necessary.

Although his height was 2.22 SD below the mean for age at his initial visit  it was not unexpected as his weight was affected even more than his height and bone age was significantly delayed. He most likely has a combination of constitutional delay in growth and nutritional growth retardation.

Children with constitutional delay constitute one of the most common clinical problems encountered in pediatric endocrine clinics. It is defined by Prader as: "constitutional delay of growth occurring in otherwise healthy adolescents with stature reduced for chronological age but generally appropriate for bone age and stage of pubertal development, both of which are usually delayed" Similarly nutritional growth retardation patients may cease to gain appropriate weight and fail to grow in height even without exhibiting body weight deficits for height.

Growth hormone treatment is not the standard of care for either constitutional delay in growth and /or nutritional growth retardation.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a diagnosis of primary hyperparathyroidism and human immunodeficiency virus (HIV). She has no history of (h/o) renal stones. Her DEXA (Dual X-ray Absorptiometry) scan revealed Osteopenia. She had refused to undergo neck surgery and therefore she was started on Sensipar therapy by her endocrinologist  The health plan's determination is overturned.
The patient has a history of hypercalcemia from primary hyperparathyroidism. She had refused to undergo parathyroid surgery and also the neck ultrasound was not able to localize parathyroid adenomas. Per a review of the clinical documentation, the Sensipar did lower her calcium levels to within the reference range. The Sensipar therapy is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria

Treatment: Breast Augmentation

The insurer denied: Breast augmentation. That denial was reversed.

The patient is transgender.  The patient was prescribed hormone therapy for gender dysphoria.  The patient is doing well on hormone therapy, but her breasts have not developed more fully.  The patient's doctors have determined the patient is now ready for gender reassignment surgery.

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:

Criteria for Breast/Chest Surgery (One Referral)
Criteria for breast augmentation (implants/lipofilling) in MtF patients:
1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery.  The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

The patient meets these guidelines.  She has well documented gender dysphoria and has been on hormone therapy for years.  Breast growth with hormone therapy has been maximized.  She is the age of majority.  Significant mental health concerns are not documented.  The requested breast augmentation is consistent with the WPATH criteria and is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperthyroidism
Treatment: Inpatient admission
The inpatient admission was not medically necessary. The patient could have been managed at a lower intensity of care than acute inpatient care.
There were no unique circumstances in this patient's hospital course to warrant acute inpatient care.  Parathyroidectomy can be accomplished safely in the outpatient setting or through observation. There is extensive literature supporting these approaches.  Calcium monitoring and empiric calcium supplementation have been proven to be efficacious in avoiding postoperative complications of hypocalcemia.  This patient had an uneventful course of hospital management and could have been managed at a lower level of intensity than acute inpatient care. Literature is provided both in regard to outpatient parathyroidectomy and total thyroidectomy (which has a higher potential risk of global parathyroid depression).
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a recent diagnosis of lymphoma who presented with diarrhea, abdominal pain, and reproducible chest pain for the past two days. He also endorsed a fever and body aches. Given concerns for potential colitis, the patient was subsequently admitted to the hospital. He was started on intravenous (IV) antibiotics. Inpatient admission was not medically necessary. This patient's symptoms resolved quickly enough that stool studies were not able to be sent. Though he met systemic inflammatory response syndrome (SIRS) criteria, it was felt that his fever was in the setting of known lymphoma and not a new infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza B; Evaluation of Fever
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

The male patient with past medical history significant for hypertension, diabetes mellitus, dyslipidemia, asthma, and obesity who presented to the Emergency Department with complaints of fever and sore throat.
Vitals on presentation included a temperature of 103.1F, a blood pressure of 176/85, a pulse of 109, a respiratory rate of 23, and an oxygen saturation of 97% on room air.  Laboratory values were notable for the following: a white blood cell (WBC) count of 7.3, a hemoglobin of 12.3, a hematocrit of 37.9, a creatinine of 1.0, and a glucose of 113.  Serology screening was Influenza B positive. Laboratory results confirmed Influenza B positive.  Tamiflu was also started.  A chest x-ray was clear.  The patient remained afebrile, hemodynamically stable and clinically improved.  He was discharged to continue management as an outpatient.
According to patient documentation, he presented with fever and a non-productive cough.  The only positive finding was influenza B. A chest x-ray was negative and there was no evidence for a systemic infection.  Progress notes recorded "no wbc, no sputum, no pneumonia, not suspicious for bacterial infection, blood cultures not indicated ..." 

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

The patient has a history of prior morbid obesity status/post (s/p) sleeve gastrectomy with 50 pound weight loss and resolution of hypertension (HTN) and known bilateral thyroid nodules suspicious for papillary carcinoma on fine needle aspiration (FNA) biopsies. The patient underwent elective bilateral thyroidectomy. The procedure was uncomplicated and uneventful. The patient was able to tolerate intake by mouth,(po) and pain was controlled with oral medication. The patient had stable labs and was discharged home on 9/27/18. The health plan's determination is upheld.

Elective thyroidectomy that is uncomplicated and without significant medical co-morbid status or other medical or surgical complication can be managed at a lower level of care status, and inpatient is not medically necessary. This patient's procedure was uneventful, and the post-operative care was uncomplicated, and the patient met all standard discharge criteria tolerating oral intake and pain was controlled with oral medication. This patient had no complicated co-morbid conditions or other post-surgical complication that required inpatient or extended stay.
Appeal type: Medical necessity
Decision: Overturned


The patient was admitted for acute inpatient level care for worsening symptoms of depression and suicidal ideation. The patient presented with a history of major depressive disorder and prior treatment by her neurologist with Wellbutrin. Her referral was prompted by her daughter's concern that she was suicidal in the context of severe psychosocial stressors and decline in functioning. The patient was giving away her belongings, withdrawing from family, and making suicidal statements indicating that she would be better off dead. At the time of her referral, she had incurred a surgical procedure to remove an ovarian cyst.

The patient had received a comprehensive medical evaluation prior to admission. She was admitted with subsequent safety monitoring and treatment with milieu therapy that included group, educational and activity therapies. She received medication with continued treatment with Wellbutrin and the addition of Prozac, as well as as needed (prn) medications to address anxiety and insomnia. She engaged in therapeutic interventions within the treatment milieu including group, individual and educational sessions. The treatment team and case manager were working to develop a safe and clinically appropriate discharge plan and disposition in concert with her family.

By the last day of her brief inpatient stay, the patient was noted to be adherent to medication and participating in the therapeutic interventions. She was calmer with normal speech that was clear and thoughts that were linear and logical, as before. She denied suicidal ideation or any urges to self-harm. Discharge planning had occurred and the patient was discharged with clinically appropriate aftercare and continued medications, as well as the safety plan developed in concert with her daughter with whom she lived and follow up appointments for continued mental health services.

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is overturned. The patient had severe symptoms of depression, she was a safety risk, and, outpatient treatment had failed to prevent the worsening symptoms of depression with onset of severe symptoms in the context of severe psychosocial stressors and the recent surgical procedure immediately prior to her admission. The patient remained a safety risk and functionally impaired with high risk for relapse if discharged from acute inpatient level care earlier and the patient needed to reach a stable baseline of functioning with assurance of medication tolerability with a solid disposition and safety plan prior to discharge from inpatient level care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia
 
Treatment: Medication- Repatha Sureclick

The insurer denied coverage for Repatha Sureclick. The denial was reversed.
The patient is a male with a history of hyperlipidemia.  He had tried atorvastatin 40 mg and simvastatin 10 mg/day, however was not able to tolerate any higher doses due to extreme side effects.  He had been on Crestor which caused weakness.  Lipitor caused joint aches.  He had a strong family history of premature atherosclerotic cardiovascular disease.  The patient had an elevated coronary calcium score.  LDL level was 162 mg/dL while taking simvastatin 10 mg/day.  His provider noted his LDL has been above 190 mg/dL off therapy.  Repatha was requested. 

The patient tried and failed several high and low intensity statins, including high dose and lowest possible tolerated dose, all of which resulted in intolerable myalgias as well as inadequate LDL reduction to a goal of < 70 mg/dL.  There was no history of clinical atherosclerotic cardiovascular disease. However, the patient had the diagnosis of familial hyperlipidemia as evidenced by untreated and on-treatment LDL levels.  The use of PCSK9 inhibitors is appropriate and medically necessary with respect to their proven reduction of cardiovascular events.  As such, the requested medication is approved. 

The use of Repatha Sureclick is medically necessary for this patient. The carrier's denial of coverage for Repatha SureClick is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient diagnosed with idiopathic short stature (ISS).  This request is for Genotropin.  The health plan's determination is upheld. 

The patient did not meet biochemical criteria.  Growth hormone stimulation testing is not reported.  The patient does not have a pretreatment height less than or equal to -2.25 SD.  Therefore, patient does not meet idiopathic short stature criteria.  The request does not meet any nationally accepted criteria for use of growth hormone.  The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness and Elevated Troponin.  

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a female patient who has a history of diabetes with polyneuropathy, hypertension, hyperlipidemia, and a long history of coronary artery disease with multiple percutaneous coronary interventions followed by coronary artery bypass graft (CABG) x3 in 2003. (Home medications included aspirin, atorvastatin, insulin, carvedilol, gabapentin, glimepiride, Januvia, lisinopril, losartan, metformin, and ranitidine. 
In late 2018 she was seen in another Emergency Department (ED) for an episode of chest pain on awakening, accompanied by diaphoresis, evaluated in the ED with two normal troponin levels and sent home.  She continued to have chest heaviness with intermittent sharp chest pain lasting several minutes was seen by her cardiologist who ordered an outpatient troponin which was 0.04, and presented to the ED on this admission in late 2018.  Initial vital signs included blood pressure 133/74, heart rate 70, respiratory rate 18, temperature 980F and oxygen saturation on room air 97%.  EKG is described as revealing normal sinus rhythm with T wave inversions in I and aVL.  diffuse hypokineses, and a small area of probable apical akinesis with mild to moderately decreased left ventricular systolic function.  She was treated with aspirin 325 mg in the ED, continued on her home medications, and transferred to another facility diagnostic coronary angiography. 
There is no evidence for ST segment elevation myocardial infarction, ongoing myocardial ischemia, significant arrhythmias or hemodynamic instability.  

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

Diagnosis: Mood dysregulation
Treatment: Residential mental health treatment 
The residential mental health treatment was not medically necessary.
Nothing in the documentation reviewed indicates that this patient was behaviorally out-of-control, unable to care for her own needs, or presented a danger to self to the extent that she required 24-hour confinement and treatment. Furthermore, there is no evidence of psychiatric involvement beyond the initial assessment. Nothing in the chart indicates that this patient could not have been treated safely and probably more effectively in a mental health partial hospital program in her community.