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

Diagnosis: Endocrine/Metabolic/Nutritional -short stature.
Treatment: Pharmacy/Prescription Drugs-Norditropin.
The health plan denied Norditropin as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This is a male patient diagnosed with short stature. This request is for Norditropin. As reported; he has a Mosaic with a karyotype45/46 Xy and 95 % of his cells 45 X. He is being raised as a male. He is status/post  resection of Right streak gonad. Left testes biopsy showed immature testes. Labs at 2 weeks of age with luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were normal pubertal; testosterone was 226; anti-mullerian hormone (AMH) was 20. His left testicle on ultrasound (US)  was normal and in the scrotum. His height velocity is reported to be 7 cm/yr. (centimeters per year). His genitourinary (GU) exam was at tanner 1 (1 testicle was palpated and it was prepubertal). His bone age  was 5year-6year at chronological age (CA) 4year 10month.
His height at 2 y/o (years old)was 80 centimeter (cm) (-1.95 standard deviation score (SDS)) and  at 4.835 y/o was 92.8 cm (-3.34 SDS) with height velocity over 2.835 y of 4.4 cm/yr.

The request for Norditropin is medically necessary for this patient.
Growth hormone(GH) in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 standard deviation (SD). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. Idiopathic short stature is a diagnosis of exclusion. Given the fact that the patient has (short stature homeobox-containing gene) SHOX deficiency as described below causing the short stature, the patient does not have idiopathic short stature
GH is indicated and FDA approved in patients with Turner Syndrome (TS) and patients with SHOX deficiency. Patients with SHOX deficiency benefit from GH to the same degree as do patients with TS
The patient has a karyotype that is missing one sex chromosome. The patient has a deficiency and SHOX severe short stature and growth failure. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute diverticulitis. 
Treatment: Full hospital admission. 

The insurer is denied coverage for full hospital admission. 
The denial is overturned. 

This female patient has a history of urinary tract infections (UTI), irritable bowel syndrome (IBS), and endometriosis. 

According to Milliman Care Guidelines (MCG) Care Guidelines Inpatient and Surgical Care 25th Edition Diverticulitis, Acute ORG: M-150 (ISC) the Clinical Indications for Admission to Inpatient Care include Admission may be indicated for 1 or more of the following: Peritoneal signs; Hemodynamic instability;  Persistent gross bleeding per rectum (e.g. resulting in drop in hematocrit) ; Significant abnormality on imaging study, including: abscess necessitating inpatient care (i.e. need for IV(Intravenous) antibiotics, clinical monitoring, or drainage not performable in observation care),  Immunocompromised patient (e.g., chronic systemic corticosteroid use, neutropenia, end-stage renal disease, AIDS(Acquired immunodeficiency syndrome), transplant patient); Need for inpatient surgical intervention; Bacteremia; Severe pain requiring acute inpatient management;  Vomiting that is severe or persistent; Dehydration that is severe or persistent; Inability to maintain oral hydration (e.g., needs IV fluid support) that persists despite observation care; Parenteral nutrition regimen that must be implemented on inpatient basis. Thus, the patient did meet these criteria for inpatient admission due to the finding of an intramural collection which could have required drainage. They needed to follow the patient to make sure that she improved. Once she improved, she was able to be discharged. The patient had complicated acute diverticulitis given the finding on CT(Computed tomography) of the abdomen and therefore did not qualify to be treated as an outpatient/observation. 

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 the full hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia. 
Treatment: Inpatient Mental Health. 

The insurer is denied coverage for Inpatient Mental Health. 
The denial is overturned. 

This female patient has a history of schizophrenia. 

The Interqual 2019 Behavioral Health-Adult and Geriatric Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, post-traumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning then meet criteria for inpatient treatment. Also, if symptoms improved but the patient was not clinically stable for discharge or was a high risk for rehospitalization or a high risk of harm to self or others then criteria would have still been met. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, or inability to care for basic needs required hospital treatment. 

In this case the chart notes did report that she had the continued psychotic symptoms during the denial period including continued auditory hallucinations of a male voice telling her not to trust the staff, and she had continued paranoid thinking, depressed mood, disorganized thinking, and poor ADL(Activities of daily living) so she was not able to adequately care for self during the denial period if not in this 24-hour hospital. Also, the likelihood of her worsening her symptoms if she were to leave the hospital was high while she still reported psychotic symptoms, so she was not ready to be discharged yet from this 24-hour hospital when she had no further reports of hallucinations or delusions, and her mood was improved and bright with no suicidal or homicidal ideation, and her insight reportedly improved.  She was considered at risk to decompensate with her psychotic symptoms and was considered not yet able to adequately care for her basic needs if discharged prematurely. 

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 the Inpatient Mental Health is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: PSA (prostate specific antigen)

Treatment: procedure code 72195 (Magnetic resonance [eg, proton] imaging, pelvis; without contrast material(s))

The insurer denied coverage for procedure code 72195 (Magnetic resonance [eg, proton] imaging, pelvis; without contrast material(s)).

The denial is upheld.

This is a male with past medical history of atrial fibrillation (Afib), anxiety, depression, hypertension, increased PSA (prostate specific antigen) and malignant neoplasm. The patient underwent a multiparametric-magnetic resonance imaging (mp-MRI) of the prostate for further evaluation of the elevated PSA. The MRI revealed PIRADS-4 (prostate imaging reporting and data system) lesion in the left posteromedial prostate apex suspicious for prostate cancer. The Urologist indicated that the MRI of the prostate was medically necessary. 

The appeal by the patient is noted and read in detail. This patient had his prostate cancer diagnosed by a transrectal ultrasound (u/s) with u/s-guided biopsies. Prostate cancer was found only on the right lobe of the prostate, not in the left lobe that was deemed to be suspicious by the mp-MRI performed prior to the prostate u/s with biopsies. The mp-MRI is not considered standard of care for evaluation of elevated PSA. The standard of care is still transrectal prostate ultrasound/ biopsy). MP-MRI may be useful in very select cases; a patient with an elevated PSA/ abnormal exam but prostate ultrasound/biopsy is negative for prostate cancer. MP-MRI is also useful in active surveillance of biopsy-proven low grade or favorable intermediate-risk prostate cancer to rule out areas of suspected higher-grade disease.

There was sufficient evidence to support that procedure code 72195 (Magnetic resonance [eg, proton] imaging, pelvis; without contrast material(s)) was not considered medically necessary treatment for the patient's condition.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for procedure code 72195 (Magnetic resonance [eg, proton] imaging, pelvis; without contrast material(s)) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis Vulgaris
Treatment: Otezla (Pre-Service)
The insurer denied the Otezla (Pre-Service)
The denial is overturned. 

The patient is a woman with psoriasis for whom Otezla is requested. According to the dermatologist's letter, the patient had previously been prescribed Elidel (periorbital use), clobetasol for approximately a month (unsafe for long-term use), and Derma-Smoothe/FS scalp oil to which she had an adverse reaction (little to no relief, unsafe for long-term use).

Yes, the proposed Otezla is medically necessary.
Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene)  This patient has severe psoriasis as evidenced by facial and scalp lesions (sensitive areas, difficult to treat) that have failed multiple therapies for which therapy with Otezla is appropriate and medically necessary. 

Conventional systemic therapy and phototherapy are not appropriate choices for this patient because of her childbearing age (acitretin and methotrexate are teratogenic) and the location of lesions on sun-exposed areas which indicates that ultraviolet light is not helpful for this particular patient. Otezla is not contraindicated in pregnancy and the mechanism of action is not influenced by ultraviolet light. It is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene).

In the era of small molecule and biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior. Based on the above data, Otezla is medically necessary for this patient.

The proposed therapies are not appropriate for this patient. With psoriasis of the face and head, phototherapy is not an appropriate option for treatment as these are difficult to treat, sun-exposed areas which shows ultraviolet light is not helpful. Cyclosporine is not a reasonable long-term option for the patient because of the side effect profile which precludes long-term use when other options are available.  Methotrexate has life-threatening side effects and a much more severe side effect profile than Otezla.  In the era of small molecules (Otezla) and biologic therapies for psoriasis, the use of methotrexate, cyclosporine, or acitretin (acitretin is contraindicated in women of childbearing potential) is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to newer therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Pain

Treatment genicular nerve injection to treat knee pain

The insurer denied coverage for genicular nerve injection to treat knee pain.

The denial is upheld.

This patient has a history of super morbid obesity (BMI [body mass index] 58.6), sleep apnea, kidney stones, carpal tunnel syndrome, amputation below the knee on the left side with stump pain and phantom pain and has pain after a total right knee replacement. 

She presented to the pain management physician's office for the evaluation of 10 out of 10 left knee pain. She takes Lyrica 600 milligrams (mg) per 24 hours without relief. She also tried Cymbalta and Amitriptyline without relief. She has tried heat and ice therapy and a home exercise program. The physician recommended obtaining magnetic resonance imaging (MRI) of the lumbar spine or a computed tomography (CT) scan in order to receive clearance for dorsal root ganglion stimulation. He also recommended genicular nerve blocks to treat knee pain.   She has had 2 prior genicular nerve blocks with steroids which have provided long lasting 85% (percent) relief.

The use of genicular nerve blocks here is supported only with case series reports (1,2,3) with small numbers and limited follow-up. 

There are evidence-based therapies available such as Spinal cord stimulation or intra-thecal pump therapy.  The requested therapy is not medically reasonable or necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a genicular nerve injection to treat knee pain is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease

Treatment Endari (L-Glutamine)

The insurer denied coverage for Endari (L-Glutamine)

The denial is upheld

The patient has been diagnosed with a past medical history of acute chest syndrome due to hemoglobin S (sickle cell trait) disease, asthma, Beta 0 (absence of beta globin) thalassemia, and sickle cell disease. The patient's medications are hydroxyurea, folic acid, Oxbryta, Adakveo, and Endari. The treating provider is requesting plan approval for treatment with Endari (L-Glutamine).

The treating provider is requesting plan approval for treatment with Endari (L-Glutamine). The patient needs Endari (L-Glutamine) to treat and prevent further progression of the patient's disease, to prevent hospitalization and vaso-occlusive crisis (VOC). The patient has been diagnosed with a past medical history of acute chest syndrome due to hemoglobin S disease, asthma, Beta 0 thalassemia, and sickle cell disease. The patient's medications are hydroxyurea, folic acid, Oxbryta, Adakveo, and Endari.

"Hydroxyurea, a myelosuppressive agent, is the only effective drug proven to reduce the frequency of painful episodes. It raises the level of HbF [fetal hemoglobin] and the hemoglobin level. It usually decreases the rate of painful episodes by 50 % (percent). It was first tested in sickle cell disease in 1984." (Agrawal, et al., 2014).

"Sickle cell anemia (SCA) is a severe, inherited hemoglobin disorder affecting 100,000 persons in the US [united states] and millions worldwide. Hydroxyurea, a once daily oral medication, has emerged as the primary disease-modifying therapy for SCA. The accumulated body of evidence over 30 years demonstrates that hydroxyurea is a safe and effective therapy for SCA." (McGann, et al., 2015).

In the study by Nihara et al., patients "had had at least two pain crises (no upper limit) documented during the previous year." 

The Office Note indicates, the patient has been diagnosed with a past medical history of acute chest syndrome due to hemoglobin S disease, asthma, Beta 0 thalassemia, and sickle cell disease. The patient's medications are hydroxyurea, folic acid, Oxbryta, Adakveo, and Endari. This patient has been on Hydroxyurea since 2016.

The Office Note indicates, that this patient has been on Hydroxyurea. As such, plan provisions may be met. However, there is no supporting documentation to know if hydroxyurea had been effective. The medical note does not indicate when the two episodes of chest syndrome had taken place.      

Endari is indicated to reduce the acute complications of sickle cell disease in adult and  patients five years of age and older. Food and Drug Administration (FDA) Until clarified that Hydroxyurea had not prevented these episodes of chest syndrome, Endari would not be considered medically necessary. 

Therefore, the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for Endari (L-Glutamine) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man with hypertension and diabetes who presented to the emergency room (ER) with substernal chest pain associated with dizziness, nausea and vomiting. Symptoms began 4 hours prior to arrival in ER. He reported having had a negative coronary angiogram several years prior. Blood pressure (BP) was 175/116, decreasing to 143/95 following nitroglycerin. Pulse was 67 beats per minute (bpm) and he was afebrile. He was admitted to telemetry

The inpatient stay is not medically necessary in this case. The patient presented with chest pain, but had a low HEART score, predicting a low likelihood of significant adverse cardiac events. He does not meet Milliman Criteria for inpatient admission for chest pain, as he was hemodynamically stable, had cardiac biomarkers that were negative and an electrocardiogram (EKG) that did not show ischemic changes. He did have significant hypertension on presentation and did not have evidence for target organ damage. His BP was controlled within the first 24 hours of hospitalization. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Osteoarthritis/Joint Problem/Pain
Treatment: Home Health Care - CDPAP increase in hours
The health plan denied the increase in consumer directed personal assistance program (CDPAP) services as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history significant for chronic degenerative joint disease, knee pain, gait difficulty, lower back pain, lumbar radiculopathy, osteoarthritis, hand pain, hypertension, and osteoporosis.

Patient is requesting an increase in consumer directed personal assistance program (CDPAP) hours to 4 days a week times () 8 hours a day, for a total of 32 hours a week. Patient has been approved for 3.5 hours per day  4 days a week, for a total 14 hours a week. Additional services were denied stating the following: You are able to walk with light touch and assistance with a cane or walker. Patient has assistive devices at home to help her with her needs. Based upon the most recent Uniform Assessment System (UAS) State of New York assessment, your personal care needs can be met with 3.5 hours per day  4 days a week, for a total 14 hours a week. Granting additional hours are not provided when tasks are not being performed. Patient is appealing the decision.

The requested health service is not medically necessary for this patient.

The patient has past medical history listed above, which includes osteoarthritis, chronic joint pain, gait dysfunction, and generalized debility. A tasking tool noted the patient required a total of 3.5 hours a day  4 days a week of services. Most of the services include meal preparation and ordinary housework.

A more recent tasking tool noted patient required a total of 4 hours a day  4 days a week of services. Most of the time includes time for housework and meal preparation.

From review of the information provided, it appears that the patient's physical function is very similar from the previous assessment to this more current assessment. There does not appear to be any significant changes in her functional level which require additional medical services for activities of daily living (ADLs) or instrumental activities of daily living (IADLs).

The services provided are adequate to meet her needs. Most of her personal care including IADLs and ADLs are secondary to her immobility and chronic pain issues. These include assistance with ADLs, i.e. housekeeping and meal preparation. Patient is able to walk into her apartment with the help of an assistive device. She is able to transfer on and off the toilet using grab bars and cane for support. She is able to perform normal hygiene when items are placed close to her. According to the Uniform Assessment System (UAS) these needs have been met adequately.