Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Specific Antibody Deficiency.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested treatment.
The health plan's determination is upheld.

The patient is a male with a history of hidradenitis suppurativa (HS), chronic sinusitis, and type 2 diabetes. He has required surgical drainage of the lesions and antibiotics for his HS. He has a history of chronic sinusitis and experiences recurrent sinusitis about 4-6 times per year, and this has been supported by positive sinus computed tomography (CT) scans. The sinus infections typically last 4-8 weeks on antibiotics. He recently received 2 months of antibiotics with Clindamycin and Doxycycline for sinusitis. The otorhinolaryngologist (ENT doctor) has had difficulty controlling his sinusitis. He does not have nasal polyps.
The patient also has symptoms of severe headaches, neck stiffness, jaw discomfort, tooth pain and anxiety, which began after a car accident when he was a teenager. He also experiences intermittent dry mouth, low grade fever, abdominal pain and nausea. Rheumatologist evaluation has not revealed an autoimmune disorder.

His doctor's assessment was that the patient has a possible autoinflmmatory syndrome. Due to poor antibody response to S. pneumonia, he considered treatment with supplemental immunoglobulin for treatment of specific antibody deficiency.

The health plan's determination is upheld in whole.

No, the proposed treatment with Hyqvia is not likely to be more beneficial than any standard treatment for the patient's condition.
This is because while the provider has prescribed Hyqvia for treatment of specific antibody deficiency (SAD) - it is not clear that this patient has a definitive diagnosis of SAD, because there is no documentation of the pneumococcal vaccine being administered 4-8 weeks prior to the follow up assessment of pneumococcal titers. It has been demonstrated by this patient that the patient has a documented history of recurrent sinus infections requiring multiple and prolonged rounds of antibiotics. However, based on the documentation provided for review, it is not clear that this patient has a definitive diagnosis of SAD.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Specific Antibody Deficiency.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested treatment.
The health plan's determination is overturned.

The patient is a male with hidradenititis suppurativa and chronic infectious sinusitis diagnosed with selective antibody deficiency (SAD) by an allergist/immunologist. The patient had a poor response to Pneumovax and low avidity to pneumococcus by formal lab testing. The patient has elevated levels of the immunoglobulins IgG, IgG4, and IgA with a normal IgM and elevated B cell (lymphocyte) numbers (CD20+). Sinusitis is poorly controlled with appropriate topical therapies and oral antibiotics under an otolaryngologist's care.

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

Yes. Hyqvia is more likely to be of benefit than the standard, already failed treatments of nasal irrigation, oral antibiotics and intranasal steroids for recurrent infectious sinusitis. The patient has minimal allergic disease but significant abnormalities in immunoglobulin function with documented abnormal response to pneumococcal vaccination (Orange et al). The most appropriate therapeutic choice is immunoglobulin replacement therapy to reduce the frequency and severity of sinus infections (Bonilla et al, 2015; Sumit et al 2016).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Specific Antibody Deficiency.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested treatment. 
The health plan's determination is upheld.

This is a male with Specific Antibody Deficiency (SAD) who is requesting  Hyqvia. He has a history of infections. IgG, IgA are high. IgM is normal. Pneumococcal titers were at least 1.3 in 3/23 serotypes. There is no vaccination date.

Uphold. There are no randomized control studies which have studied the efficacy of Hyqvia for SAD.

No. Per 2015 update to the Practice Parameter on Immunodeficiency, "Regarding Specific Antibody Deficiency (SAD), Summary Statement 105. The diagnosis of SAD should be given to patients older than 2 years with recurrent respiratory tract infections, normal immunoglobulin an IgG subclass levels, and impaired response to pneumococcal capsular polysaccharide."
Regarding treatment of SAD, the authors note "Summary statement 106. Patients with SAD might benefit from additional immunization with conjugate pneumococcal vaccines, intensified use of antibiotics, and in some cases a period of IgG replacement therapy."
Per Orange, J. S., & Barllow, M. (2017) "Specific antibody deficiency (SAD) is a primary immunodeficiency disease characterized by normal immunoglobulins (Igs), IgA, IgM, total IgG, and IgG subclass levels, but with recurrent infection and diminished antibody responses to polysaccharide antigens following vaccination. There is a lack of consensus regarding the diagnosis and treatment of SAD, and its clinical significance is not well understood. Here, we discuss current evidence and challenges regarding the diagnosis and treatment of SAD. SAD is normally diagnosed by determining protective titers in response to the 23-valent pneumococcal polysaccharide vaccine. However, the definition of an adequate response to immunization remains controversial, including the magnitude of response and number of pneumococcal serotypes needed to determine a normal response. Confounding these issues anti-polysaccharide antibody responses are age-and probably serotype dependent. Therapeutic strategies and options for patients with SAD are often based on clinical experience due to the lack of focused studies and absence of a robust case definition. The mainstay of therapy for patients with SAD is antibiotic prophylaxis. However, there is no consensus regarding the frequency and severity of infections warranting antibiotic prophylaxis and no standardized regimens and no studies of efficacy. Published expert guidelines and opinions have recommended IgG therapy, which are supported by observations from retrospective studies, although definitive data are lacking. In summary, there is currently a lack of evidence regarding the efficacy of therapeutic strategies for patients with SAD."
 In this case, the patient has not tried prophylactic antibiotics. Additionally, there are no randomized control studies which have studied the efficacy of Hyqvia for SAD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis

Treatment: Total hip replacement

The insurer denied coverage for total hip replacement.

The denial is upheld.

This female patient was evaluated for pain to her left hip.  The patient was a reported as an every day smoker, 1 packs every 3 days. The patient's body mass index (BMI) was 33.99.  The patient's physical examination demonstrated limited internal rotation which reproduced groin pain. The patient's X-rays showed mild degenerative disease. The patient was diagnosed with osteoarthritis and total hip surgery was scheduled. 

Based on the medical record, the patient's physician had recommended Meloxicam and provided a corticosteroid injection. The physician recommended the need for a left total hip replacement (THR) at that time. The patient had left total hip arthroscopy (THA) that showed degenerative changes. The patient reported continued pain after her left hip arthroscopy.  No physical examination was completed and the physician opined osteoarthritis. The physician recommended left total hip replacement.

Based on the review of the medical record and literature, the documentation submitted for review does not support that this patient meet the criteria for the left total hip replacement. The criteria cited were a person would have to stop smoking at least two months prior to surgery.  This is applicable as the scientific literature has reported increased risk of complications and healing problems as compared to nonsmokers.  The medical record was significant for smoking status defined at each visit.  The patient was an active smoker, smoking one pack every three days. There was no documentation in the office visits that she had been counseled or stopped smoking. Singh, et al. in a study involving 7926 patients who underwent either total knee or total hip arthroplasty stated "We noted that current tobacco use was associated with high risk of deep infection and implant revision after primary THA or TKA."  Similar findings were noted by Duchman, et al. The criteria also reported that there must be documentation regarding discussion of weight loss.  The patient's BMI was 33.99, which was elevated.  Studies have shown that people who have elevated BMI appear to be at higher risk for complications. (Haynes, et al; Deakin et al).

Based upon the records reviewed and criteria, the left total hip replacement would not be medically necessary for this patient at this time. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Total Hip Replacement; CPT code 27132 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 in this case is a woman who was diagnosed with Burkitt lymphoma.  Two weeks before the hospital admission she developed sudden onset abdominal swelling and she was evaluated by her primary care physician.  Computed tomography (CT) scans were done and revealed bilateral ovarian masses along with peritoneal metastatic disease, mesenteric infiltration and multiple hepatic hypodense lesions.  Biopsy was done.  She was discharged pending the results of biopsy. 

The patient developed further abdominal distention and shortness of breath and presented to an out-of-network facility.  She underwent IR guided paracentesis.  The emergency room (ER) physician was contacted by the previous facility with a diagnosis of Burkitt Lymphoma.  The patient had no hemodynamic instability at the time of diagnosis.  She had anemia but renal function was intact.  Lactic acid was elevated, and uric acid was 9.1.  

The patient was admitted to the hospital and she was started on induction chemotherapy with CODOX.  She was to have a lumbar puncture with intrathecal chemotherapy treatment.  She required repeat paracentesis with removal of four liters.  Her course of therapy was complicated by tumor lysis syndrome that caused acute kidney injury.  She also developed severe mucositis and febrile neutropenia during her hospital stay.  She required treatment with broad spectrum antibiotics.  She had recurrent fever and also was found to have a bleeding gastric ulcer for which she required endoscopy and clipping.  She was treated with a proton pump inhibitor, to be taken twice daily for eight weeks.   She was eventually discharged to home with home physical therapy. 

No, the proposed inpatient admission was not medically necessary.  

This patient was diagnosed with Burkitt lymphoma and required urgent chemotherapy treatment.  This was appropriate in the inpatient setting but did not need to be done at an out-of-network facility.  This patient could have been safely treated at an in-network facility.  The patient had symptomatic ascites but no hemodynamic instability or other significant acute medical issue that would have required urgent admission, as opposed to her traveling a couple of hours to an in-network facility for admission and treatment with combination chemotherapy.  There is no documentation indicating that this patient required treatment at an out-of-network facility because of an urgent acute medical issue (such as hemodynamic instability, severe acute infection, active tumor lysis syndrome, acute kidney injury or other similarly severe acute condition) or because there was no in-network facility able to treat her condition.  Therefore, the out-of-network admission in this case was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Depression.
Treatment Inpatient mental health.
The insurer denied the inpatient mental health stay. The health plan's determination is overturned in part. 14 additional days are medically necessary. 

This case involves an adult male who called 911 and was brought by emergency services to the emergency department and admitted for acute inpatient psychiatric treatment. The patient had become increasingly depressed with suicidal ideation, and deterioration in functioning culminating in his presentation to the emergency department and admission after medical screening. He had a history of mood disorder best characterized as bipolar mood disorder with severe depressive episodes and psychiatric treatment with therapy and medications. He had co-occurring substance use disorders including opioid use disorder in treatment with methadone maintenance, and use of cannabis and benzodiazepines.

14 additional days are medically necessary. The patient's presentation and clinical features included severe symptoms of mood disorder, suicidal risk, and deterioration in functioning in the context of substance use disorder. The patient remained at risk for relapse and suicidal behavior during the time interval under review to day 14 when he no longer represented a safety concern and was functioning better with improved symptoms and medication adherence. Additionally, a safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse. The patient could not have been expected to participate in treatment at a lower level of care in this case scenario until he had stabilized. In this regard, the patient no longer warranted continued acute inpatient level services from day 14 forward.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, polyuria, and dry mouth
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a male who presented with abdominal pain, polyuria, and dry mouth. He had a history of heavy alcohol use. He had a prior hospitalization and found to have liver disease. 

The patient's blood pressure was 128/84 and heart rate was 97. He was found to have a glucose of 496, anion gap of 21, carbon dioxide of 23, pH of 7.4, beta hydroxy-butyrate of 3.8, and an A1C of 11.5%. Abdominal ultrasound showed hepatic steatosis and biliary sludge. The patient underwent computed tomography (CT) of the abdomen to evaluated abdominal pain and possible pancreatitis, which was pending at time of discharge. The patient was treated with intravenous fluids and intravenous insulin. He was then switched subcutaneous insulin. 

No, the inpatient admission was not medically necessary.

This patient presented with hyperglycemia and dehydration in the setting of newly diagnosed type II diabetes. The patient was hemodynamically stable. He did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. He had mild dehydration that responded to intravenous fluids. The documentation does not support that he failed management under a lower level of care. He had abdominal pain and his ultrasound showed hepatic steatosis and biliary sludge and did not show an acute process that required inpatient admission. For his new onset diabetes, he was started on subcutaneous insulin, received diabetes education, and was discharged the following day. Therefore, no, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient hospital. 
The insurer denied the inpatient stay. 
The denial is upheld in whole.

The patient is a male with a history of hypertension, diabetes, heart failure with preserved ejection fraction, and obesity. He presented to the emergency department complaining of several days of sharp left-sided chest pain and dyspnea that was worsened with exertion. His blood pressure was 168/89 millimeters of mercury (mmHg) with a heart rate of 65 beats/minute. His room air oxygen saturation was 100%. His physical exam was notable for obesity and a systolic murmur and was otherwise unremarkable. His electrocardiogram showed sinus rhythm with nonspecific repolarization changes. His serum troponin level was normal. His brain natriuretic peptide (BNP) level was mildly elevated. The patient was admitted to the hospital to rule out acute coronary syndrome. A repeat troponin level was normal. The following day he denied chest pain. His troponin level remained normal. An echocardiogram showed normal left ventricular systolic function. There was mild left atrial enlargement and mild left ventricular hypertrophy. There was grade I diastolic dysfunction. The patient was discharged home with plans for outpatient cardiac tress testing. Medical necessity for an inpatient stay is at issue.

The health plan's determination is upheld in whole.

An inpatient hospital stay was not medically necessary for this patient.
This patient, with multiple cardiac risk factors, presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. He was hemodynamically stable, with normal serum troponin levels, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially life-threatening diagnoses were considered likely. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: shortness of breath.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This baby was brought to the Hospital for increased work of breathing. The patient was not in distress. The patient was noted to have 3 to 4 days of increased work of breathing (WOB), upper respiratory infection (URI), decreased by mouth (PO) intake. The temperature was 38.1 degree Celsius, heart rate (HR) 130 to 150, respiratory rate (RR) 48 and SpO2 95 % on room air (RA). A chest x-ray (CXR) showed no definite infiltrate. 

The inpatient hospital admission was not medically necessary. The patient did not have perinatal risk factors such as chronic lung disease nor prematurity. Also, there was no risk factor such as congenital heart disease. There is also other reassuring factors such as lack of "distress" , normal CXR, normal WBC, normal blood culture, SpO2 95 % on RA, bicarbonate in BMP > 16, age >1 month, and lack of RSV or Influenza . As per American Academy of Pediatrics (AAP) guideline for managing bronchiolitis, patients can be safely discharged if they are not dehydrated. Also, if one were to examine the Pediatric Early Warning Score (PEWS) the score would be 0 most of the time which portends a stable clinical course. The PEWS is a score that predicts unstable clinical course that can be measured in ED or pediatric floor. If the score is less than 4, patients most likely will have stable clinical course. Observation at a lower level of care was appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic hypersomnia
Treatment: Modafinil 200mg OR TABS
The insurer denied the Modafinil 200mg OR TABS.
The denial is overturned. 

The patient is a male who presented with excessive daytime sleepiness. He underwent polysomnography (PSG) with multiple sleep latency test (MSLT).  The diagnosis was consistent with idiopathic hypersomnia. The request is for Modafinil.

Yes, the prposed treatment with Modafinil is medically necessary in this patient at this time. 

The American Academy of Sleep Medicine recommends the use of the following central nervous system (CNS) stimulants as an option as there is no standard of care medication approved by the FDA for the treatment of this condition.  The medications include:
- methylphenidate
- amphetamine/ methamphetamine
- Modafinil/armodafinil.

Therefore, the use of Modafinil in this patient with idiopathic hypersomnia is medically necessary as supported by the American Academy of Sleep Medicine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Schizophrenia; substance abuse.
Treatment:  Inpatient mental health stay.

The insurer denied coverage for a continued inpatient mental health stay.  The denial is upheld. 

This a female, who was admitted for inpatient mental health treatment due to psychotic symptoms including derogatory auditory hallucinations, talking to self, internal preoccupation, paranoid delusional thinking, noncompliance with medications, depressed mood, suicidal thoughts, and daily use of crack/cocaine use.  The patient had a positive toxicology for opiates, cocaine, and cannabinoids.  The patient had multiple past reported psychiatric hospitalizations.  The patient reportedly was homeless and lacked support.  The patient was admitted and was treated with adjustment of medication regimen.  She was then discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  In this case, as of several days prior to discharge, there were no reports of further serious psychiatric symptoms, such as hallucinations, delusions, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability.  The patient had reports of derogatory auditory hallucinations, talking to self, internal preoccupation, paranoid delusional thinking, noncompliance with medications, depressed mood, and suicidal thoughts on admission, but not several days prior to discharge.  Notes reported that the patient denied suicidal or homicidal ideation, hallucinations, delusions, and she had normal speech, okay mood, and was well related.  She also had goal-directed thought process.

Based on the review of the medical record, the patient reportedly had no further acute or serious psychotic symptoms or serious behavioral or mood symptoms as of the first date under review.  There were no reports of acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting as of then or that could not be achieved in a less restrictive level of care as of then.  Thus, continued inpatient mental health treatment was not medically necessary for this patient.

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

Based on the above, the medical necessity for the continued inpatient mental health admission is not substantiated.  The insurer's denial should be upheld.