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

Diagnosis: Ectopic Pregnancy

Treatment: Emergent hospital admission

The insurer denied coverage for emergent hospital admission.

The denial is upheld.

The patient had prior history of a cesarean scar ectopic pregnancy treated with methotrexate and potassium chloride with subsequent interventional radiology embolization who presented to the Emergency Department (ED) with complaints of heavy vaginal bleeding, mild crampy lower abdominal pain and lightheadedness. She was noted to be tachycardic with a heart rate of 131 beats per minute (bpm). Obstetrics/Gynecology (OB/GYN) was consulted and planned for Cytotec administration, a blood transfusion and an emergent dilation and curettage (D&C). Intravenous (IV) fluids were started and she received Cytotec. The patient called for an ambulance to transport her to receive treatment from her primary OB/GYN physician, leaving against medical advice (AMA).

The patient presented with a diagnosis of ectopic pregnancy and vaginal bleeding. Because of tachycardia, the plan was to transfuse her, give her Cytotec and do a D&C. However, she left before her test results came back (hematocrit was 29.2). Only Cytotec was given. A D&C is an ambulatory procedure. D&Cs are done in offices and surgicenters. Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Admission to an acute level of care is not customary or medically necessary.

Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission. Note that the patient was never transfused or had a D&C as she signed out AMA.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. The emergent hospital admission is not considered medically necessary for this patient. 

Based on the above, the medical necessity for an emergent hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Universalis. 
Treatment: Xeljanz. 

The insurer denied coverage for Xeljanz. 

The denial is overturned. 

The patient has a diagnosis of alopecia universalis.  He has been stable on his current treatment plan of Xeljanz for years. It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following years of use which has resulted in disease control without significant adverse effects.  As a result, the use of xeljanz is medically necessary.  

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

The insurer's denial of coverage for Xeljanz is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: thyroidectomy

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is overturned. 

This female patient has a history of malignant neoplasm of the thyroid with grade I follicular lymphoma.

Milliman Care Guidelines (MCG) Health Ambulatory Surgery Discharge and Complications: Common Complications and Conditions 24th edition1 states that an indication for inpatient care may require inpatient stay one or more of a  number of conditions.   The patient met two of the requirements for an inpatient stay in that she has  an  American Society of Anesthesiology (ASA) equal to 3 and that this was a complex surgical procedure because of the recurrence of the thyroid cancer and Non-Hodgkin's Lymphoma, Stage Ill with enlarged lymph nodes which took 2 hours and 56 minutes. 

The patient fulfilled two of the requirements only one of which was necessary for inpatient stay as noted by MCG Health Ambulatory Surgery Discharge and Complications: Common Complications and Conditions 24th edition1. These were an ASA = (equal) 3 and undergoing a prolonged complex operative procedure for the removal of recurrent thyroid capital.

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

The carrier's denial of coverage for inpatient admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Specific development disorder of motor function
Treatment: Physical therapy
The insurer denied the physical therapy.
The denial is upheld.

This is a male child with evidence of "inconsistent progress with areas of regression performing gross motor skills that are age-appropriate." Physical therapy records report abnormal postural alignment secondary to weakness, decreased balance, vestibular instability, hypotonicity, decreased coordination. In addition, overpronation of both feet, bilateral knee valgus, hip internal rotation, w-sitting, diminished stair negotiation abilities, risk of falls. Child has been engaged in skilled physical therapy.

This is a child with gross motor delays. Clinical records do not contain evidence of physician supported diagnosis and specific referral for goal-oriented physical therapy. Medical necessity for ongoing physical therapy cannot be established due to insufficient evidence in support of physical therapy interventions.

This child received early intervention services through pre-school services. He has been granted additional visits to bridge the gap in early intervention services. Health plan granted considerable amount of therapies and provided ample opportunities for the family education and establishment of school-based therapies. The patient is independent in ambulatory skills and age-appropriate developmental goals. There is no evidence of new diagnosis, clinical intervention requiring short-term restorative goal-oriented PT (physical therapy) with physician prescription. In fact, the clinical records are devoid of physician-supported diagnosis and medical necessity for additional PT interventions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankylosing Spondylitis with Severe Polyarthritis

Treatment: Medication Humira 40 milligrams

The insurer denied coverage for medication Humira 40 milligrams.

The denial is overturned.

This case involves a female who has a history of ankylosing spondylitis with severe polyarthritis manifested by hand and wrist involvement as well as the axial involvement of the spine. The documentation indicated that the patient has a negative rheumatoid factor (RF) and cyclic citrullinated peptide (CCP) and therefore she best fits the category of seronegative arthritis or spondylarthritis. She has had a trial of failure of Naprosyn, ibuprofen, and diclofenac. Given the axial involvement, sulfasalazine would not be indicated as appropriate. The patient is not a candidate for methotrexate as she is of childbearing age. The recommendation has been made for this patient to utilize Humira. The submitted documentation does include a chart note indicating the patient presented with joint pain. She has pain in the back as well as pain in the shoulders and neck. There has also been progressive pain and swelling to the hands, thumbs, feet, and knees. Over the years, the physician indicated she has not been evaluated; however, she saw rheumatology. The documentation indicated she does have red patches to her neck, which her dermatologist indicated were psoriasis. The physical examination indicated there was no peripheral edema. She had normal muscle strength. Her Crohn's disease activity index (CDAI) score was 16. The physician indicated the patient does have a history of polyarthritis with right greater than left peripheral arthritis as well as axial symptoms. Given history of seronegative arthritis, the physician detailed it was possible that this was a seronegative category. The recommendation was made for a further work-up to include imaging, as well as multiple laboratory studies.

This case is an individual who has ankylosing spondylitis with severe polyarthritis, as well as psoriatic patches. She is of childbearing age and therefore methotrexate would be contraindicated. Given this scenario, the requested Humira is appropriate. The health plan did not act reasonably or in the best interest of the patient. 

Based on the above, the medical necessity for the medication Humira 40 milligrams is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/ Neuromuscular Disorder 
Treatment: Inpatient rehabilitation 
The insurer denied acute rehabilitation as medically necessary.
The denial is overturned. 

The patient has a medical history significant for astrocytoma status/post (s/p) resection, s/p ventriculoperitoneal (VP) shunt, Factor V Leiden with strokes and intracerebral hemorrhage (ICH) who was admitted to the hospital previously for constipation but developed worsening dysphagia with medical history significant for factor V Leiden thrombophilia with recurrent strokes. Prior to his recent admission, documentation states that patient was able to be left home alone but did note some assistance with activities of daily living (ADLs).
Unfortunately, the latest hospital documentation noted that the patient had a sharp decline with a magnetic resonance imaging (MRI) scan of the brain "showing small acute tiny right capsular region stroke. Also, evidence of bil calcification around thalamic region." Following this stroke, the patient required assistance of 2 people to stand, dependent feeding, increased difficulty with secretions and bowel and bladder incontinence. Therapy noted that sit to stand transfers were completed with contact guard assist (CGA) / Minimal assistance (MINA) of 2 with grab bar to walker. Also on this date, the patient ambulated 285' with a wheeled walker (WW) MINA / moderate assistance (MODA)MODA of 2 with therapy noting patient to have scissoring gait pattern and posterior retropulsion which improved with cueing. Documentation also noted that patient required a pureed, thickened liquid diet. Meanwhile, a gastrostomy tube (g-tube) was placed for nutrition. During this time, the patient also required intravenous (IV) antibiotics for infection. The doctor noted that patient was not medically ready for discharge and "will need to be at goal feedings prior to discharge." Once patient was tolerating tube feedings it would be appropriate for discharge to acute rehab as the patient had a diagnosis of a new stroke with functional decline, needed multidisciplinary therapy of physical therapy/occupational therapy/speech therapy, had developed bowel and bladder incontinence requiring medical management of neurogenic bowel/bladder, needed close monitoring of nutrition, could tolerate 3 hours of therapy/day, 5 days per week, and because of the patient's clinical complexity required a medical practitioner to provide an assessment at least 3x/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Triptodur. 
The denial is overturned. 

This is a male diagnosed with central precocious puberty (CPP). This request is for Triptodur. As reported; he has congenital adrenal hyperplasia (CAH). His luteinizing hormone (LH) was 0.5; follicle-stimulating hormone (FSH) was 0.7; sex hormone binding globulin (SHBG) was 88.4; Testosterone was 23. He is on hydrocortisone. The subject under review is the medical necessity for Triptodur. 

The health plan's determination is overturned. 

Triptodur is medically necessary. The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 in girls and younger than age 9.5 in boys [1-3]. Central precocious puberty (CPP) is diagnosed using a basal LH of greater than (>) 0.3 or stimulation testing with a gonadotropin-releasing hormone (GnRH) analog such as leuprolide showing a pubertal response defined as an LH >5 and estradiol greater than 40 [4]. CPP is treated with GnRH agonists [5-10] such as Lupron [11] and Supprelin [12]. The Food and Drug Administration (FDA) indication for GnRH agonists is for use in central precocious puberty (CPP). The patient has an advanced bone age and congenital adrenal hyperplasia causing the advanced bone age and onset of central puberty. Imaging is not necessary in this case as the cause of central puberty is known. The request for Triptodur is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Prosthetics 
The insurer denied right prosthetic leg. 
The health plan's denial is overturned. 

The patient is a female with right transfemoral amputation. She has congenital shortening of her right lower extremity. The request is for right leg prosthesis. The subject under review is the medical necessity for the artificial leg.

The health plan's determination is overturned in whole. 

The requested service of a right prosthetic leg is medically necessary and appropriate. She requires a well-fitted prosthetic to be able to ambulate safely. Her current prosthetic is several years old.

The patient has congenital shortening of her right lower extremity. She has had the same prosthesis for years. This is a complicated case, though, because apparently she was provided a prosthetic which did not fit her and the company refused to fix this issue. She returned this prosthetic. She is still wearing her prosthetic from several years ago, which is worn and does not fit. She needs a new prosthetic to be able to safely complete all activities of daily living. This patient has not received appropriate care and the company received payment for a prosthetic that was ultimately returned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: PET/CT scan
The insurer denied the PET/CT scan.
The determination is upheld.

The patient is diagnosed with a rapidly progressive dementia. The neurologist indicated that the condition is not consistent with Alzheimer's disease. A serum paraneoplastic panel was negative and did not discover any pathologic antibodies. Analysis of the cerebrospinal fluid did not show oligoclonal banding. The physician has ordered a positron emission tomography/computed tomography (PET/CT) scan to evaluate the patient for an occult malignancy resulting in a paraneoplastic process as the cause of her rapidly progressive dementia. The patient has a history of breast cancer. The medical necessity of the PET/CT scan is under review.

The requested PET/CT scan is not medically necessary. The patient is diagnosed with rapidly progressive dementia. The causes of rapidly progressive dementias are broad and include infectious, autoimmune, toxic/metabolic, neoplasm related, and endocrine related. In this particularly instance, the physician has indicated that there is particular concern for a neoplasm-related cause of the rapidly progressive dementia. In evaluation for a malignancy, the initial work-up would include a CT scan of the body with and without contrast and/or a mammogram, especially given the patient's history of breast cancer. There is no documentation available to this reviewer that these initial studies were performed. Similarly, laboratory work for malignancy would include lactate dehydrogenase (LDH) and tumor markers. Although an extensive laboratory evaluation was performed, this reviewer did not find the results of this testing. Lastly, if a patient is posited to have an occult malignancy, standard of care might also involve referral to an oncologist.
As the initial imaging (CT scan of the body and mammogram) has not been performed, medical necessity for a PET/CT scan has not been demonstrated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis.
Treatment: Rinvoq 15mg OR TAB 24.
The insurer denied the Rinvoq 15mg OR TAB 24.
The denial is upheld.

This patient is a female with history of rheumatoid arthritis. The patient has a history of elevated alpha-fetoprotein.   The patient was started on Rinvoq through products samples.  She has had a good clinical response to the Rinvoq.  

Rinvoq was initially denied because the patient has not previously tried and failed leflunomide, hydroxychloroquine or sulfasalazine.	The reason the provider is appealing the determination is because the provider states the patient is unwilling to do methotrexate and she was started on Rinvoq products samples and clinically has been doing well.

No, the proposed treatment is not medically necessary.
The patient has new onset potential rheumatoid arthritis.  Symptoms have only been present for two weeks and not the six weeks or more that is used in the clinical guidelines to diagnose rheumatoid arthritis.  There was synovitis of the wrists on exam but no other joints.  The C-reactive protein (CRP) level was minimally elevated.  No x-ray reports were submitted to show any erosive changes.  The rheumatoid factor is mildly elevated with negative anti-CCP antibody(cyclic citrullinated peptide).  The clinical notes report that the alpha-fetoprotein is elevated at 8.8 with likely normal range for their lab being less than (<)8.0.  There is no ultrasound report to suggest fatty liver or labs to suggest elevated liver function tests.  The patient can have elevated alpha-fetoprotein and not be concerning for cancer.  There is no other contraindication to the use of methotrexate.  That being said, there is also no other contraindication to the use of other conventional disease modifying anti-rheumatic drugs (DMARDs) such as hydroxychloroquine, leflunomide or sulfasalazine.  The American College of Rheumatology guidelines in the treatment of rheumatoid arthritis do recommend the use of methotrexate and maximizing methotrexate prior to advancing to biologic disease modifying anti-rheumatic drugs (DMARDs).  Therefore, the proposed treatment is not medically necessary.

Yes, the health plan did act reasonably with sound medical judgment and in the best interest of the patient.
The plan acted in accordance with the American College of Rheumatology guidelines in the treatment of rheumatoid arthritis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dysphagia and nausea.

Treatment: D6010, surgical placement of implant body

The insurer is denied coverage for D6010, surgical placement of implant body

The denial is upheld. 

This female patient has no documented history.

Upon review of the objective documentation which primarily consists of panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. In regard to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment. 

Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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 D6010, surgical placement of implant body is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pediatric Growth Hormone Deficiency (GHD)
Treatment: Genotropin
The insurer denied the Genotropin.
The denial is overturned.

The patient is a female with the diagnosis of multiple pituitary deficiencies in the setting of septo-optic dysplasia. The patient has GH (growth hormone), ACTH (adrenocorticotropic hormone) and TSH (thyroid stimulating hormone) deficiency. The patient's height is at -2.32 SDS (standard deviation score). The patient has been on GH (growth hormone) treatment for several years. In addition to GH (growth hormone) treatment, the patient received steroids and thyroid hormone replacement. Growth chart with height was provided.

Yes, the Genotropin is medically necessary.
This patient has the diagnosis of GHD (growth hormone deficiency) in the setting of septo-optic dysplasia with 2 other pituitary hormone deficiencies ACTH (adrenocorticotropic hormone) and TSH (thyroid stimulating hormone).

Septo-optic dysplasia is a disorder of early brain development. A major feature of this disorder is pituitary hypoplasia which is usually accompanied by multiple hormone deficiencies. Most commonly, pituitary hypoplasia causes growth hormone deficiency, which results in slow growth and unusually short stature and hypoglycemia during the early years, such as this patient, who has been on treatment for several years.

Genetic etiologies of Isolated Growth Hormone Deficiency (IGHD) and Combined Pituitary Hormone Deficiency (CPHD) have demonstrated a role for several factors in the etiology of IGHD/CPHD (Isolated Growth Hormone Deficiency/ Combined Pituitary Hormone Deficiency). Mutations in the GH1 (growth hormone 1) and GHRHR (growth hormone releasing hormone receptor ) genes shed light on the phenotype and pathogenesis of IGHD (Isolated Growth Hormone Deficiency) whereas mutations in transcription factors such as HESX1 (homeobox expressed in embryonic stem cells 1), PROP1 (homeobox protein prophet of pituitary-specific positive transcription factor 1), POU1F1 (Pituitary-Specific Positive Transcription Factor 1), LHX3 (LIN-11, Isl-1 and MEC-3 Homeobox 3), LHX4 (LIN-11, Isl-1 and MEC-3 Homeobox 4), GLI2 (Zinc Finger Protein GLI2) and SOX3 (Sex Determining Region Y-Box Transcription Factor 3) contributed to the understanding of CPHD (Combined Pituitary Hormone Deficiency). Depending upon the expression patterns of these molecules, the phenotype may consist of isolated hypopituitarism, or more complex disorders such as septo-optic dysplasia and holoprosencephaly.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient needs to be treated with growth hormone, not only for its effect on growth, but also for its metabolic effects in body composition and bone health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: missing teeth and partials.
Treatment: dental implants for teeth 2 - 15, 18, 19, 20, 28, and 29 with extraction of tooth 20.
The insurer is denied coverage for dental implants for teeth 2 - 15, 18, 19, 20, 28, and 29 with extraction of tooth 20.
The denial is upheld. 

This female patient has a history of missing teeth and partials.

The patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment  to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures, which the patient already has and presumably have been functional. Further the documentation provided does not support, justify or substantiate the required treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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 dental implants for teeth 2 - 15, 18, 19, 20, 28, and 29 with extraction of tooth 20 is upheld.  The medical necessity is not substantiated.