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

Diagnosis: Digestive System/ Gastrointestinal.
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld in whole. 

The patient is a female who presented to the hospital emergency department (ED) with severe epigastric and right upper abdominal pain, nausea and vomiting. Comorbid health conditions included diabetes, renal cell cancer, obesity, and hypertension. She was hemodynamically stable at the time of presentation. She was tender in the epigastrium. The white blood cell (WBC) count was 9 thousand (K). Ultrasound identified gallstones and a minimally thickened gallbladder wall. The complete metabolic panel identified normal serum transaminases. Bilirubin was normal. She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The surgical consultation indicates that the diagnosis was that of symptomatic cholelithiasis rather than acute cholecystitis.
Her pain improved, vitals remained normal, and the diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting with instructions to obtain an outpatient hepatobiliary iminodiacetic acid (HIDA) scan.
The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld, in whole.

Inpatient admission was not medically necessary in this case. This is a patient with diabetes, a history of renal cell cancer, obesity, and hypertension who presented to the ED with cholelithiasis/cholecystitis. The evaluation identified gallstones and normal serum chemistries. She was hemodynamically stable at the time of presentation. Cholecystectomy was indicated based on the ED evaluation. The surgical notes include alternative diagnoses (symptomatic cholelithiasis rather than acute cholecystitis) for this patient with upper abdominal pain, nausea, vomiting, and gallstones. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation.
There is no documentation of failure to achieve discharge criteria, performance of surgery, care for comorbidities that required inpatient care, procedural complications, or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level of care status.

The Milliman Care Guidelines (MCG)-Gallbladder or Bile Duct Inflammation, 23rd edition were reviewed. These MCG state that the goal length of stay is ambulatory, but that extended stay may be required in the setting of failure to achieve discharge status, systemic infection, care for comorbidities or complications of the procedure, or other condition that requires inpatient admission.
In this case, none of these indications existed to justify an inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea

Treatment: Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T)

The insurer denied the Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T)

The denial was overturned.

This is a female patient who has been diagnosed with obstructive sleep apnea as well as breast cancer, hypothyroidism, papillary carcinoma thyroid, arrhythmia and bilateral trigeminal neuralgia. The patient's trigeminal neuralgia she cannot utilize a CPAP mask.  The submitted documentation indicated this patient has undergone a sleep endoscopy confirming she does not have complete concentric collapse of the upper airway.  The submitted documentation also indicated this patient has undergone a sleep study resulting in an AHI of 32.7.  The physician detailed given the patient's comorbidities and presence of obstructive sleep apnea the best available treatment would be a hypoglossal nerve stimulation system.

The Inspire surgical procedure, also known as upper airway stimulation procedure, should be approved for the patient. This procedure has been approved by the FDA since 2014; it is no longer considered investigational treatment. Patient meets all of the criteria for implantation of this inspire device. She is intolerant to CPAP due to her trigeminal neuralgia. She has a history of snoring, frequent nighttime awakenings, daytime fatigue and severe obstructive sleep apnea (with less than 25% central sleep apnea events). 2019 sleep study reveals an AHI of 32.7. Her BMI is acceptable at 25. She is not a candidate for oral appliance therapy, according to her sleep surgeon Dr. Maria Suurna. Dr. Suurna performed a DISE (drug induced sleep endoscopy) procedure, which showed no concentric collapse of the soft palate. The patient meets all of the criteria for the inspire hypoglossal nerve stimulator implant procedure (also known as the upper airway stimulation procedure); she is an excellent candidate for this procedure. This procedure is likely to be more beneficial that any other standard health service. 

The carrier's denial of Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T) should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left C7 radiculopathy
Treatment: Inpatient admission
The insurer denied the Left C7 radiculopathy.
The denial is overturned.

The patient is a male with history of left C7 radiculopathy who underwent C67 cervical keyhole foraminotomy which was complicated by dorsal root sleeve durotomy which was primarily repaired. Postoperatively, the patient showed no new postoperative complaints. The patient was admitted overnight for monitoring with hospitalization.

Yes, the health plan should cover the proposed inpatient admission.

The patient had an intraoperative complication with cerebral spinal fluid (CSF) leak which required primary closure. This type of complication can lead to issues in the immediate postoperative period; the patient needs to be closely monitored for this issues which require immediate intervention if experienced (such as CSF leak from the wound, fluid collection and compression and other issues that do require acute inpatient hospitalization). In the setting of this type of neurological complication, acute inpatient hospitalization with overnight monitoring is appropriate.  Standard of care supports admitting this patient to inpatient level of care due to the level of monitoring required and the need for immediate intervention should an issue occur.  Therefore, the health plan should cover the inpatient admission.

Yes, the inpatient admission was medically necessary. The inpatient admission does meet the definition provided for medical necessity because this type of complication requires close monitoring postoperatively and this can only be done at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Increased shortness of breath.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female with a history of hypertension and pulmonary embolism with worsening shortness of breath.  She was admitted to acute in hospital level of care for the work up of shortness of breath.

No, the inpatient admission was not medically necessary.

The emergency evaluation included computed tomography (CT) of the chest, which did not show any pathology.  The blood work was with in normal limits.  The patient was hemodynamically stable.  The other work-up included lower extremity Dopplers, which ruled out deep vein thrombosis (DVT), as well as echocardiogram.  The work-up after the emergency room could have been safely and effectively been provided as an outpatient care.  Since the patient had shortness of breath, acute coronary syndrome was ruled out in the emergency room.  The acute in hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Gender Dysphoria
Treatment:Surgical services

Diagnosis: Gender Dysphoria/ Female to male
Treatment: Surgical services/ Mastectomy
The health  plan denied the procedure as not medically necessary. The health plan determination is upheld.

This is a female to male transgender patient. Breast surgery was performed 10 years ago but the patient has pain and discomfort in the chest due to the redundant skin and breast tissue in both axillae. Dermatitis and intertrigo have required treatment with over-the-counter (OTC) and prescription medications. Repeat top surgery is planned.

The requested health service of Mastectomy, simple, complete, and full thickness graft is not medically necessary for this patient.
The patient has already had top surgery. He is reported to have excess skin that is causing intertrigo and rashes, but the records do not include photos that show rashes or include treatment notes from his primary care physician documenting treatment for the rashes from the redundant breast tissue. The patient is reported to have dermatitis and intertrigo.  The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment.  In addition, photos showing chafing are not provided for review. Supporting PCP or dermatology note documentation should be provided to confirm the history provided by the patient to the plastic surgeon.
The procedure will improve the appearance of the patient's chest wall. The patient has already had top surgery, and revision is not medically necessary in the absence of photos and PCP or dermatology note documentation of treatment for rashes.
The WPATH guidelines support trans-gender top surgery. In this case, the patient has already had top surgery but is not happy with the outcome of the surgery. Photos showing the patient's chest are not provided, and therefore it is not possible to independently verify that that the patient's result is outside the range of expected outcomes following top surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weight Loss
Treatment: Pharmacy/Prescription Drugs (Saxenda)
The health plan denied the requested prescription drug. 
The health plan's determination is overturned.

The patient is a female with a history of obesity.
The coverage request is for Saxenda 3mg/0.5 ml pen injector.
The patient had lost 17% of her body weight  on Saxenda and a weight loss program (personal trainer and small group weight loss program and gym use), however was unable to lose more in the 6 month of the preceding period due to COVID and gyms being closed. Her body mass index (BMI) was 35.1 and is 34.9 currently; she was not aware she had to continue to lose 5% to allow Saxenda to be reauthorized.

The health plan's determination of medical necessity is overturned, in whole.

Yes, Saxenda is medically necessary for this patient.
The patient is stating that during COVID she did not have access to gyms; she was not aware of the 5% weight loss required. 
Saxenda is recommended as one of the first line agents in pharmacologic treatment of obesity, and in clinical trials after 1 year was able to produce about 8kg of weight loss (Khera et al. 2016). This patient has experienced well over 5% loss of baseline body weight in the first 6 months of use - this is defined as successful weight loss effect based on AACE 2016 and Endocrine Society 2015 guidelines on obesity pharmacotherapy.
The previous denial of Saxenda does not accept the COVID lockdown as an extenuating circumstance as to why the patient did not lose 5% of body weight in the first 6 months of 2020 - however this reviewer believes the COVID lockdown IS an extenuating circumstance for which a onetime exception should be made to determining medical necessity. Even though the patient can exercise without gyms - the lack of support from group programs and in-person coaching and gym equipment altogether is a significant decrease in weight loss aides during COVID that might not be reasonably overcome by simply exercising on one's own outside.
The patient has had good success with a structured weight loss program and with Saxenda prior to the COVID lockdown and has maintained her weight during the lockdown.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Infectious Disease. 
Treatment: Lab Work/Blood Tests. 
The insurer denied: 87491, 87591, 82652. 
The denial is overturned in part.

The patient is a male without significant past medical history who had vitamin D 1,25 dihydroxy blood test and chlamydia and gonorrhea nucleic acid testing. The diagnosis code for testing was Z29.8, Encounter for other specified prophylactic measure. The insurer denied coverage as not medically necessary.

Lab procedure 87491 and 87591 are medically necessary, and 82652 is not medically necessary.
The patient is a young male and sexually transmitted disease (STD) testing is a recommended screening for sexually active males and females depending on sexual orientation and sexual activity. Per UpToDate.com "The major rationale for chlamydia and gonorrhea screening among men is to reduce infection or reinfection of existing partners and transmission to new partners."
If a patient requests STD testing at an appointment that would be sufficient to order such testing without further investigation as to why the patient would want to be tested.   A provider may inquire if the patient feels they need to be tested for STDs as part of routine screening and if the patient agrees there may not necessarily be further discussion of symptoms, frequency of intercourse or sexual preference.  Certainly, a sexual history is appropriate to obtain from a patient but sometimes patients are not willing to disclose a detailed sexual history.  Given such, STD testing is medically necessary.  Young adults are sexually active and young adults should be screened for STDs even without specific symptoms or concerns. STD testing is medically necessary in this young male.    
There have been no specific medical societies who have recommended screening for Vitamin D deficiency and the U.S. Preventative Task for cites insufficient evidence to recommend routine screening for Vitamin D deficiency, therefore it was not medically necessary to screen for vitamin D deficiency in the absence of chronic kidney disease or intestinal absorption problems.  
The United States Preventive Services Task Force (USPSTF) found no studies that evaluated the direct benefit of screening for vitamin D deficiency in adults. The USPSTF found adequate evidence that treatment of asymptomatic vitamin D deficiency has no benefit on cancer, type 2 diabetes mellitus, risk for death in community-dwelling adults, and risk for fractures in persons not selected on the basis of being at high risk for fractures. The USPSTF found inadequate evidence on the benefit of treatment of asymptomatic vitamin D deficiency on other outcomes, including psychosocial and physical functioning. Although the evidence is adequate for a few limited outcomes, the overall evidence on the early treatment of asymptomatic, screen-detected vitamin D deficiency in adults to improve overall health outcomes is inadequate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin disorders/ dermatitis
Treatment: Pharmacy prescription drugs 
The insurer denied Dupixent
The denial is upheld in whole

The patient with moderate to severe atopic dermatitis (76% body surface area involvement) of the hands, fingers, arms, and legs. The patient has tried and failed topical steroids (such as triamcinolone, clobetasol, alclometasone, betamethasone, fluocinonide, halobetasol, and desonide), tacrolimus, and Eucrisa.
Dupixent is the subject under review for medical necessity.
No, the requested Dupixent is not medically necessary for this patient. The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications such as Methotrexate, Azathioprine, or Cyclosporine. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies.
Atopic dermatitis is an ongoing inflammatory disease affecting the skin, with the need to control any immune/inflammatory hypersensitivity being for some patients intermittent, and for some patients to be controlled on a chronic and ongoing basis.
The usual treatment is with topical steroids and topical immunomodulators (2-5), emolliation, mild soap, avoidance of irritants, and similar conservative treatments. Weather changes, physical illness, and even emotional stress can trigger atopic dermatitis. Topical steroids, topical Elidel and topical tacrolimus are the mainstay of therapy for this condition.
While Dupixent is a promising new agent in the systemic treatment of atopic dermatitis, it is not confirmed to be significantly superior to these alternative, and time-tested oral and light therapies described above. To date, this patient has had no past history of systemic therapies.
Accordingly, while systemic therapy is indicated for this patient, and Dupixent is one form of systemic therapy, and not medically necessary because other, more studied alternatives have not yet been tried to date. The request for Dupixent is therefore not medically necessary for this patient's particular clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins of the Lower Extremities with Other Complications
Treatment: Surgical Services-Closure of Left Anterior Accessory Saphenous Vein, Phlebectomies of Right Leg
The health plan has denied the requested surgical services. 
The health plan's determination has been upheld.


The patient is a female who presents with symptomatic bilateral lower extremity varicose veins. Her main symptom includes fatigue. Her provider notes they continue to worsen. The provider documents in a clinical note that the patient "does not use compression stockings". Duplex ultrasound demonstrates reflux in her left anterior accessory great saphenous vein. The provider is recommending a right anterior accessory saphenous vein ablation and a bilateral stab phlebectomy for treatment of her condition.

The health plan's determination of medical necessity is upheld, in whole.

No. The requested closure of the left anterior accessory saphenous vein and bilateral leg stab phlebectomies are not medically necessary because there is insufficient documentation that the patient has been compliant with compression stockings for at least three months.
The patient presents with bilateral lower extremity symptomatic varicose veins. In the provider's clinical note, the provider documents that "the patient does not use compression stockings". There is no documentation that compression stockings have been used in the past or that the patient has failed conservative therapy. Other standard of care conservative therapies includes leg elevation, avoidance of prolonged standing, exercise, weight control, and over the counter analgesics. There is no documentation that these measures have been attempted and failed. CMS (Medicare) requires a period of compression stocking use of at least three months with documentation by the provider that the patient has failed compression stocking treatment. This is also consistent with the most recent consensus guidelines from the Society for Vascular Surgery and the American Venous Forum. A positive medical necessity determination cannot be made without this clinical information provided.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male diagnosed with idiopathic short stature (ISS). This request is for Genotropin. He has attention-deficit hyperactivity disorder (ADHD). There is no growth hormone (GH) stimulation test.

No, the proposed Genotropin is not medically necessary.

The peer-reviewed literature, including consensus clinical guidelines and randomized controlled trials are summarized below.

Classic GH Deficiency: 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 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 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10ng/ml.
		
The patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported.

Idiopathic Short Stature: Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9]. Food and Drug Administration (FDA) 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 does not have a pre-treatment height less than or equal to -2.25 SD. The patient, therefore, 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.