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

Diagnosis:  Idiopathic short stature.
Treatment:  Humatrope injection 5 milligrams (mg).

The insurer denied coverage for Humatrope injection 5 milligrams (mg).  The denial is overturned. 


This patient is a female child, who has been on growth hormone (GH) therapy with Omnitrope for a diagnosis of idiopathic short stature.  A request for prior approval of Humatrope has occurred as part of a formulary switch.  The insurer has denied ongoing therapy based on a policy exclusion for idiopathic short stature. 

The patient met criteria for growth failure at diagnosis of idiopathic short stature with height velocity with Height at -2.2 SDS [standard deviations] and growth velocity at - 4.8 centimeters per year.  Consensus guidelines for the use of GH in children with idiopathic short stature suggest that the shorter the child, the greater the consideration should be given to GH use.  Furthermore, the most recent guidelines on use of GH indicate that stimulation testing should not be the only criterion governing the use of GH.

Given that this patient meets criteria for growth failure, has clearly responded to GH therapy, that current guidelines specifically caution against using the provocative test as the sole criterion for decisions regarding use of GH therapy, and that she meets consensus guidelines regarding the use of GH therapy for idiopathic short stature, it is strongly recommended that this patient be continued on GH therapy until epiphyseal fusion.

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

Based on the above, the medical necessity for Humatrope injection 5 milligrams (mg) is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with a past medical history significant for HTN (hypertension), and a family history of heart disease, fatal MI (myocardial infarction). He presented for evaluation of new onset palpitations, associated with dizziness and lightheadedness. 

The patient was found to have atrial fibrillation/atrial flutter with rapid ventricular response, pulse of 224 in the ED (emergency department). The patient was treated with IV (intravenous) Cardizem, Metoprolol and digoxin, with adequate control of the rhythm. He was then admitted to telemetry and started on Amiodarone drip. 

The patient subsequently converted to sinus bradycardia with amiodarone. An echocardiogram was obtained, revealing LVH (left ventricular hypertrophy), low normal LVEF (left ventricular ejection fraction) and mild valvular disease. The patient was transitioned to oral metoprolol and was discharged home with a plan for outpatient follow-up.

Yes, the Inpatient admission was medically necessary.

The patient presented with new onset atrial fibrillation, with severely elevated heart rate, and required multiple IV (intravenous) medications for control of his heart rate. The patient remained in rapid atrial fibrillation, despite multiple medications given in the emergency room and was admitted. He was seen in consultation by cardiology and was started on antiarrhythmic therapy with intravenous Amiodarone infusion. The patient subsequently converted to normal sinus rhythm. He was then transitioned to b-blockers. Given the acute presentation with unstable heart rate, difficult to control atrial fibrillation, failure of multiple IV (intravenous) medications in the ER (emergency room), as well as the need for IV (intravenous) antiarrhythmic use (Amiodarone), he would not be an appropriate candidate for an ED (emergency department) observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic chest wall pain

Treatment: Lidocaine 5% Patch for chronic pain

The insurer denied coverage for Lidocaine 5% Patch for chronic pain.

The denial is upheld.

This is a male patient who has chronic chest wall pain with scoliosis and slipped rib syndrome. He has tried and failed steroids, transcutaneous electrical nerve stimulation (TENS), acupuncture, chiropractic adjustments, massage, and Physical therapy. He had a trial of a Spinal Cord Stimulator which provided only 10-20% pain relief. He has had multiple intercostal nerve blocks which provide only a few days of relief. He has tried Lidoderm 5% patches and found them helpful. He has not had evidence-based therapy such as cryoablation of the intercostal nerves, intra-thecal or epidural medication trials. 

The Food and Drug Administration (FDA) approved the package insert of Lidoderm 5% transdermal for post-herpetic neuralgia. The proposed use here is off-label. Other neuropathic pain states have not shown to have better response than a placebo. 

Derry et al. conducted a meta-analysis and concluded there is "no evidence from good quality [randomized] controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm." 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Lidocaine 5% Patch for chronic pain is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced metastatic non-small cell lung cancer

Treatment: FoundationOne CDx Lab test

The insurer denied coverage for the FoundationOne CDx Lab test.

The denial is overturned. 

This is a male patient with a medical history of advanced metastatic non-small cell lung cancer (NSCLC) with metastatic disease. FoundationOne CDx Lab test was ordered by the patient's treating physician because the test results were needed to help determine the course of treatment for the patient's advanced cancer. 

The National Comprehensive Cancer Network (NCCN) supports the use of broad Next Generation Sequencing (NGS) panel testing for molecular evaluation of an individual with metastatic NSCLC.  At a minimum per the NCCN testing should include evaluation for epidermal growth factor receptor (EGFR). The NCCN does go on to state that this testing is best performed in a broad NGS panel such as foundation one.      

The FoundationOne CDx Lab test was considered medically necessary for this patient. This is in line with accepted standards of practice as outlined by the NCCN for evaluation and management of an individual with metastatic NSCLC.  As opposed to individual testing, multiplex NGS panels are felt to be more cost effective for molecular characterization. Therefore, the requested foundation one panel would be considered medical necessary.

"The NCCN Guidelines for Non-Small Cell Lung Cancer (NSCLC) address all aspects of management for NSCLC. These NCCN Guidelines Insights focus on recent updates in immunotherapy. For the 2020 update, all of the systemic therapy regimens have been categorized using a new preference stratification system; certain regimens are now recommended as 'preferred interventions,' whereas others are categorized as either 'other recommended interventions' or 'useful under certain circumstances'" (Ettinger, D. S. et al. 2019).

"From a societal perspective, our cost-effectiveness results support the value of multiplexed genetic screening and molecularly guided therapy in metastatic NSCLC" (Romanus, D. et al. 2015).                                                   

The carrier's denial of coverage for the FoundationOne CDx Lab test is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis
Treatment: Vumerity
The insurer denied Vumerity.
The health plan's determination is upheld. 

The patient is a male with relapsing multiple sclerosis initially presenting as optic neuritis. The patient is prescribed Vumerity. The drug was denied by the health plan as the patient has not tried and failed Tecfidera/dimethyl fumarate. 

Vumerity is not medically necessary. The plan indicates that the formulary alternative is Tecfidera/dimethyl fumarate. Tecfidera/dimethyl fumarate is metabolized to the same active ingredient as Vumerity. Both of these drugs are fumarate and have the same mechanism of action. Vumerity is not expected to be more effective than Tecfidera/dimethyl fumarate. There is no rationale provided as to why the patient cannot use the preferred formulary alternative or that the member has tried and failed the preferred formulary alternative. Tecfidera/dimethyl fumarate is Food and Drug Administration approved and literature supported for treatment of relapsing multiple sclerosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dizziness.
Treatment:  Inpatient admission.

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

The patient is a male.  He presented to the emergency ward with the complaint of right arm numbness and dizziness.  He was admitted for possible TIA (transient ischemic attack).  At presentation, his neurological examination was normal and CT (computerized tomography) head was negative for acute process. 

No, the inpatient admission was not medically necessary.

The patient had no deficit at presentation.  Risk stratification based on symptoms of TIA (transient ischemic attack) did not warrant acute inpatient level of care.  The diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.  Therefore, the Inpatient Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Uterine fibroids.
Treatment:  Inpatient admission.

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

The patient is a woman with a diagnosis of uterine fibroids.  She was admitted to the hospital to undergo a laparoscopic hysterectomy.  The procedure was performed without complications and a minimal blood loss.  She recovered uneventfully in the PACU (post anesthesia care unit) and was transferred in satisfactory condition with admission to the inpatient floor.  She was discharged the next day.

No, the Inpatient Admission was not medically necessary.

The medical records and medical literature were thoroughly reviewed.  A laparoscopic approach was used to perform the hysterectomy, which requires small abdominal incisions.  According to the medical records, the patient was afebrile in the PACU (post anesthesia care unit).  Her vital signs were normal and stable during the PACU (post anesthesia care unit) stay, except for a short episode of bradycardia that resolved on treatment.  The patient required IV (intravenous) pain medications for a short period of time, and her pain was satisfactorily controlled with oral pain medications overnight during the first postoperative day.  The patient recovered without incident during the hospital stay with no complications. 

According to the inpatient records, the patient had progressed to a normal diet, was ambulating without difficulty, had normal bowel sounds and a nontender abdomen by the first postoperative day.  She was noted to have flatus indicating progression of her bowel function.  Her Foley catheter was removed, and she was voiding normally. 

The patient underwent an uncomplicated laparoscopic hysterectomy.  The procedure time was not longer than expected, at two hours, and the blood loss low at 100 cc (cubic centimeters).  The post-operative period in the PACU (post anesthesia care unit) was not significantly complicated and the patient's condition was stable, with stable vital signs on discharge to the inpatient service.  The patient did not have serious co-morbidities to be a complicating factor in her preoperative and postoperative care plans.  The patient was likewise stable on admission from the PACU (post anesthesia care unit). 

Stable postoperative patients, who have undergone uncomplicated procedures such as laparoscopic hysterectomy, do not necessarily require acute inpatient admission after their discharge from the PACU (post anesthesia care unit).  They may be reliably observed, by the standard of care, in a unit providing lesser level of care prior to their eventual discharge.  Therefore, the patient in this case could have been reliably discharged from the PACU (post anesthesia care unit) to a lesser level of care rather than the acute inpatient service.  Therefore, the treatment did not have to be provided in an acute inpatient setting and was not medically necessary.  Therefore, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a history of chronic alcoholism with hypomagnesemia and hypocalcemia, hypertension, and hyperlipidemia. The patient called the Emergency Medical Services (EMS), who arrived at her home for dyspnea. The patient arrived to the Emergency Department (ED) with initial vital signs blood pressure 128/81, heart rate 109, temperature 98.5, and oxygen saturation 96% on room air. In addition to reporting dyspnea, the patient also reported chest tightness, palpitations, and weakness, and that the symptoms were similar to those she had in the past when her magnesium level was low. 

The patient's electrocardiogram (EKG) revealed sinus tachycardia at rate 102. The patient's laboratory test results included white blood cell (WBC) count 8.7, hemoglobin 11.4, creatinine 0.75, blood urea nitrogen (BUN) 8.2, sodium 134, potassium 2.9, chloride 94, magnesium 1.3, calcium 9.9, albumin 3.8, and positive urine screen for benzodiazepine. The patient was treated with oral and intravenous potassium chloride and intravenous magnesium. The patient's follow-up laboratory test results revealed potassium 3.6 and magnesium 2.4, and then potassium 3.7 and magnesium 2.1. The patient's repeat EKG was normal. The patient's computed tomography (CT) angiography of the chest did not reveal pulmonary embolus, and the patient's chest X-ray was normal. The patient was evaluated by surgery for a swollen left elbow with a blister and was treated with warm soaks. No significant arrhythmias were documented and the patient's symptoms resolved in the ED. The patient was discharged to home on day 3 of admission for outpatient management.

Based on the review of the patient's medical record and literature, there is no evidence that this patient required an acute inpatient level of care to evaluate or treat her dyspnea, hypomagnesemia, or hypokalemia. There was no evidence for significant symptoms or persistent EKG changes due to her electrolyte imbalance that required telemetry monitoring in an acute inpatient level of care. Evaluation and management should have been completed in the ED or at an observation level. Thus, inpatient hospital admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female who presented to the ED (emergency department) with a chief complaint of a one day history of moderate progressive abdominal pain following intercourse. Imaging demonstrates significant large volume hemoperitoneum on TVUS (Transvaginal Ultrasound). The plan was to admit the patient for observation with serial hematocrit measurements. 

Because of persistent pain and drop in hematocrit, a diagnostic laparoscopy with evacuation of hemoperitoneum for ruptured hemorrhagic cyst was performed the day after admission. This was without complications. The patient was discharged home later that day. 

No, the Inpatient Admission was not medically necessary. 

This patient presented with abdominal pain. She was diagnosed with a ruptured bleeding ovarian cyst. The patient was stable based on her vital signs. There were two options to manage her: 1) Take her to the operating room or 2) Observe her for improvement or worsening. 

The providers decided to observe her. Observation does not require admission. The patient could have been observed at a lower level of care, and when the provider felt that surgical intervention was necessary, she could have been taken to the operating room. Note that a diagnostic laparoscopy is an ambulatory procedure and does not require admission. 

This patient underwent a laparoscopy. A laparoscopy is an ambulatory procedure. 

According to MCG (Milliman Care Guidelines), Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for:
Older patients (> 65), Conversion to abdominal procedures, Surgical complications, Comorbidities. 

This patient did not meet any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately. 
 
In summary, this patient could have been observed for deterioration of her condition then had a laparoscopy. Neither observation nor laparoscopy require admission. 

Based on the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Thyroid eye disease.
Treatment:  Service code 67904 - Right Repair of blepharoptosis; (tarso) levator resection or advancement, external approach; 67900 Right/ Left Repair of brow ptosis (supraciliary, mid-forehead or coronal approach); 67911 Left Correction of lid retraction.

The insurer denied coverage for service code 67904 - Right Repair of blepharoptosis; (tarso) levator resection or advancement, external approach; 67900 Right/ Left Repair of brow ptosis (supraciliary, mid-forehead or coronal approach); 67911 Left Correction of lid retraction.  The denial is overturned. 

This is a male patient with a history of thyroid eye disease.  The patient has thyroid eye disease treated with radioactive iodine and thyroidectomy.  The patient had decrease in field of view bilaterally and complications from left upper eyelid retraction, and his left eye is constantly gritty and irritated.  The patient had bilateral brow ptosis with compensatory use of frontalis muscle, right upper lid (RUL) ptosis, and left upper lid (LUL) retraction, bilateral upper lid (BUL) dermatochalasis and inferior punctate erosions on the left eye.  The ophthalmologist recommended BUL blepharoplasty, RUL levator advancement, repair of LUL retraction and internal browpexy of both eyes.  

Based on the review of the medical record and literature, the requested procedures are considered medically necessary.  The patient has thyroid eye disease, resulting in RUL ptosis, left eyelid retraction, and bilateral brow ptosis.  The patient's ptosis has affected his peripheral vision, as evidenced by visual field testing.  In addition, the patient's LUL retraction has caused corneal complications (exposure keratopathy) in the left eye.  The patient's ptosis has affected the patient's vision.  The patient's clinical exam showing ptosis, frontal and lateral external photographs documenting ptosis affecting the visual axis, and visual field testing showing a superior field obstruction, all support this determination.  The repair of the left eyelid retraction is medically necessary because the patient has evidence of corneal complications from lid retraction associated with thyroid eye disease.  Clinical examination showed inferior punctate erosions in the left eye, indicating exposure keratopathy from lid retraction.  The procedure is necessary to alleviate corneal complications and prevent vision loss due to corneal exposure from lid retraction.

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 service code 67904 - Right Repair of blepharoptosis; (tarso) levator resection or advancement, external approach; 67900 Right/ Left Repair of brow ptosis (supraciliary, mid-forehead or coronal approach); 67911 Left Correction of lid retraction should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: status post laparoscopic hysterectomy and sacrocolpopexy, and urethral sling procedure with robotic assistance. 
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She who was admitted to the hospital for a laparoscopic hysterectomy and sacrocolpopexy, and urethral sling procedure with robotic assistance. The patient's co-morbidities included bipolar disorder and GERD (gastroesophageal reflux disease). 

The procedure was performed without complications and with minimal blood loss. The patient was transferred to the PACU (post anesthesia care unit), where she recovered without incident. She was then transferred to the inpatient floor, where she recovered without incident, and was discharged the following day.

No, the Inpatient admission was not medically necessary.

The medical records and medical literature were thoroughly reviewed. A laparoscopic approach was used to perform the hysterectomy and sacrocolpopexy, which requires small abdominal incisions. According to the inpatient records the patient had progressed to a normal diet, was ambulating without difficulty, had normal bowel sounds and a nontender abdomen by the first postoperative day. She was afebrile and her vital signs were normal and stable during the entire postoperative period, including in the PACU. The patient required IV pain medications for a short period of time, and her pain was satisfactorily controlled with oral pain medications at the first postoperative day. 

The patient underwent an uncomplicated laparoscopic hysterectomy and pelvic floor procedure. The procedure time was not longer than expected and the blood loss minimal. The post-operative period in the recovery room was uncomplicated and the patient's condition was stable, with stable vital signs. 

The patient did not have serious co-morbidities to be a complicating factor in her preoperative and postoperative care plans. The patient was likewise stable on discharge from the recovery room. Stable postoperative patients who have undergone uncomplicated procedures such as the above do not require acute inpatient admission. They may be reliably observed, by the standard of care, in an ambulatory or intermediate postoperative care unit prior to their eventual discharge. Therefore, the patient could have been reliably discharged from the recovery room to a lower level of care rather than an acute inpatient room. Therefore, the acute inpatient admission was not medically necessary.