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

Diagnosis: Idiopathic Short Stature.
Treatment: Nutropin AQ Injection 10MG (milligrams)/2ML (milliliters).
The insurer denied: Nutropin AQ Injection 10MG (milligrams)/2ML (milliliters).
The denial is upheld.

The patient is an adolescent male with short stature, normal IGF-1 (insulin-like growth factor) and growth hormone levels. His bone age is consistent with chronological age. In addition, he has normal pituitary hormone profile, including cortisol and prolactin. He was recently diagnosed with ADHD (attention-deficit hyperactivity disorder) and started on treatment. His height velocity slowed slightly, with the most recent one recorded at 4.4 centimeters/year. He is pre-pubertal. The patient's mid-parental height is 5'10" (70 inches). There is a family history of significantly delayed puberty in the patient's mother, whose menarche was in her late teenage years. The patent's predicted adult height according to most recent bone age is 66 inches (5'6").

The proposed treatment is not medically necessary.

The criteria for idiopathic short stature, as stated by the FDA (United States Food and Drug Administration) are height SDS (standard deviation score) < (less than) 2.25 (<1.2% for age), and a predicted adult height that is less than 63 inches (5'3") for males (5, 6, 7). The patient meets neither of these criteria, even with the recent advancement in bone age. The patient's current height is at the 8.8% which is well above 1.2% in the criteria. His predicted adult height is 66 inches (5'6"), which is also above the criteria of 5'3". While it is true that the patient's predicted adult height is less than expected for mid-parental height, this is only a consideration for treatment and not a hard and fast indication, to stand by itself. Given the overall history of delayed puberty in the patient, and family history of delayed puberty in the mother, as well as normal tracking along percentiles and normal height velocity of the patient, the patient does not meet enough considerations to warrant treatment outside the criteria. As for the last issue of "the shorter the child, the more consideration should be given," this is referencing children under the -2.25 SDS (standard deviation score) threshold, as it is also controversial whether those children should be treated. This child on the 8th percentile is not considered to be pathologically short. Normal distribution of heights includes the 8th percentile.
The references provided below include discussion on these clinical nuances. It is important to note, however, references on treatment of heights above 5th percentile are not to be found, as these are considered normal, and there are no randomized controlled trials on the use of growth hormone in children of normal heights.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and Shortness of Breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult male was hospitalized for chest pain and shortness of breath. His past medical history is significant for chronic systolic heart failure from a non-ischemic cardiomyopathy and treated with left ventricular assist device (LVAD), hypertension, pulmonary hypertension, obesity, and stroke. The patient's vital signs were stable, there was positive jugular vein distension (JVD) and lower extremity edema, left ventricular assist device hum, negative troponin, pro-brain natriuretic peptide 413, and a non-ischemic electrocardiogram (EKG). Chest film reported right basilar atelectasis / scarring. The patient's treatment included DuoNebs and intravenous Lasix with transition to oral Lasix and discharged to home with cardiology / congestive heart failure (CHF) follow-up. The request for coverage for inpatient hospitalization has been denied by the patient's policy as not medically necessary and the patient is appealing the decision.

The proposed treatment is not medically necessary.

Based on the peer reviewed medical literature, the documentation submitted for review does not establish the requested acute inpatient hospital stay was medically necessary for this patient. According to the Milliman Care Guidelines (MCG) criteria titled: Heart Failure (ORG: M-190), the inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by chronic kidney disease (CKD) and congestive heart failure (CHF), hypertension requiring inpatient hospitalization, cerebral vascular accident (CVA), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other nedical condition or other medical instability or acute care needs that would require acute inpatient management. 
In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care the patient received for mildly decompensated chronic left ventricular (LV) systolic heart failure is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted documentation and the current heart failure guidelines, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oxygen dependent chronic obstructive pulmonary disease, chronic pain, heart failure, diabetes

Treatment: Home Care/Personal Care HHC-Level II Personal 
Care Services, per 15 minutes increased to 24 Hour(s) per Day (Live in)

The insurer denied: Home Care/Personal Care HHC-Level II Personal Care Services, per 15 minutes increased to 24 Hour(s) per Day (Live in)

The denial is overturned.

This adult male has multiple medical conditions including oxygen dependent chronic obstructive pulmonary disease, chronic pain, heart failure, diabetes, bipolar disorder, and obesity. He was hospitalized six months ago after a fall that resulted in a thoracic compression fracture. He was transition to skilled nursing facility 2 months later and discharged home three months later. The patient is appealing denial of an increase of home care/personal care personal care services (PCS) to 24 hours per day, live in. The health plan approved personal care services 56 hours per week. Uniform Assessment System (UAS) evaluation completed on recently shows independent cognition and functional status: maximal assistance with meal preparation, housework, managing finances and medications, shopping, transportation, bathing, dressing, walking, locomotion, and toileting; limited assistance with personal hygiene and bed mobility; and independent with eating. He has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed 5 months earlier, there has been a decline with managing finances and medications, bathing, personal hygiene, and upper body dressing.

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. 
This patient has multiple chronic conditions. He was hospitalized with a compression fracture after a fall. He is appealing denial of increase of home care/personal care personal care services (PCS) to 24 hours per day, live in. The health plan approved personal care services 56 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires assistance with all activities of daily living (ADLs), except eating. He has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed 5 months earlier, there has been a decline with managing finances and medications, bathing, personal hygiene, and upper body dressing. This patient's physical functioning is significantly impaired. The need for maximal assistance with all activities of daily living cannot be met with the approved personal care services 56 hours per week. The proposed increase to 24 
hours per day, live in, is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiectasis

Treatment: Chest vest replacement

The insurer denied coverage for chest vest replacement

The denial is upheld

This patient has a history of Asthma/Bronchiectasis. The patient has been on bronchodilators and Mucomyst via nebulizers and inhaled corticosteroids for airway clearance for bronchiectasis. The patient had been prescribed a vest device for clearance of airway secretions. As per the patient, they have not been very compliant with the vest, using it about twice per week. The patient finds this vest too cumbersome to use due to its weight. The patient's doctor has recommended a new portable vest.

This patient was afebrile and hemodynamically stable as per an exam. The lung exam revealed coarse breath sounds. The patient's computed tomography (CT) of the chest was consistent with a diagnosis of Bronchiectasis. This patient already has a vest for assistance with airway clearance. There is no indication for an additional portable vest. There is no evidence that one type of vest is superior to the other one. The patient needs to be educated about compliance and proper technique.

Based on the above, the insurer's denial must be upheld. The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for coverage for a chest vest replacement is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short Stature.
Treatment: Genotropin.
The insurer denied: Genotropin.
The denial is: Upheld.

The patient is a male with a diagnosis of short stature. As reported; he already started to have body odor. His Insulin-like Growth Factor 1 (IGF1) was 200. His testes were 6 cubic centimeters (cc) with Tanner 2 as well as pubic hair. His weight on was 29 kilograms (kg). The office visit note does not report height velocity but reports that the patient is steadily increasing height around the 3rd to the 5th percentile. His mother's height is 152 centimeters (cm) and father's height are 170 centimeters (cm) and mid parental height is 167.5 cm (-1.30 SDS [standard deviation score]).

The subject under review is the medical necessity for Genotropin. The treating provider states he cannot use Norditropin due to the nationwide shortage and back order.
Treatment with Genotropin is not medically necessary for this patient. The patient did not meet height and height velocity criteria as pretreatment height and height velocity are normal. Growth Hormone (GH) stimulation testing peaked at less than 10 nanograms per milliliter (ng/ml).

The Pediatric Endocrine Society recommends against making a diagnosis of growth hormone deficiency based solely on failed growth hormone stimulation testing. The patient does not have a pretreatment height less than or equal to -2.25 standard deviation (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.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 diabetes.
Treatment: Formulary exception for Mounjaro.
The insurer denied: Formulary exception for Mounjaro.
The denial is overturned.

The patient is an adult male with type 2 diabetes. The request for continuation of Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. The provider is appealing this determination, because the patient is presently on basal insulin with Mounjaro. He was intolerant to metformin. He developed diabetic ketoacidosis with Jardiance. He has tried and failed Januvia due to hyperglycemia. He was intolerant to Ozempic due to nausea and vomiting. He has tolerated Mounjaro and stabilized his glucose levels and lost weight. His A1C (glycated hemoglobin) was 7% 2 months ago.

The health plan should cover the Formulary exception for Mounjaro.

This request is for Mounjaro for the treatment of type II diabetes. The prior request was denied coverage by the health plan, as the patient had not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This patient was intolerant to Ozempic due to nausea and vomiting. Ozempic and Rybelsus are both forms of semaglutide, so this patient is at high risk of also being intolerant to Rybelsus. Rybelsus is not an appropriate alternative for this patient. The remaining formulary alternatives are Trulicity and Victoza. Per the Trulicity prescribing information, the mean change in hemoglobin A1C (glycated hemoglobin) with use of Trulicity 1.5 milligrams weekly is 1.5%. (1) Per the Victoza prescribing information, the mean change in hemoglobin A1C (glycated hemoglobin) with use of Victoza 1.8 milligrams (mg) daily is 1.1%. (2) Per the Mounjaro prescribing information, the mean change in hemoglobin A1C (glycated hemoglobin) with the use of Mounjaro five (5) mg (milligrams) daily is 1.8%. (3)
This patient is currently utilizing Mounjaro and it is not clinically appropriate to withdraw therapy and substitute with a lower potency glucose lowering medication. In addition, this patient has 
already tried and was intolerant to a drug in the glucagon like-peptide-1 class, and it is not appropriate to trial additional drugs in the same class due to the high risk of him being intolerant to 
these drugs. Without Mounjaro, this patient will be at increased risk of the complications of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the 
health plan should cover the formulary exception for Mounjaro.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Parkinson's disease, terminal metastatic lung cancer.
Treatment:  Home care - nursing, nursing - home care - licensed practical nurse (LPN) per hour increase to 84 hour(s) per week.

The insurer denied coverage for home care - nursing, nursing - home care - licensed practical nurse (LPN) per hour increase to 84 hour(s) per week.  The denial is upheld.
 
This is an elderly patient with Parkinson's disease and terminal metastatic lung cancer. She also had a stroke and was recently treated for pneumonia. She lives with her spouse and daughter in a 2-bedroom apartment. The patient is approved for Consumer directed personal assistance services (CDPAS) 24 hour/day split shift and is requesting 12 of the hours/day (daytime hours) switched to LPN care.

This case was previously reviewed by this physician. Refer to prior report for detailed assessment. After reviewing the clinical records, this physician recommended an increase in CDPAS to 24 hours/day, 7 days/week (split shift). The request is now for LPN coverage; 12 of the 24 hours/day, which is not supported by the clinical records. The service needs listed by the treating physician are primarily custodial and can be provided by the family and CDPAS; monitoring, position changes, nasogastric (NG) tube feedings, breathing exercises and massages. Based on the documents reviewed, 12 hours/day of LPN services are not clinically appropriate or medically necessary. However, this physician agrees with the patient's doctor, who indicated in his progress note that continued supportive care: continuation of CDPAS 24 hours/day (split shift) remains clinically appropriate and medically necessary for this patient, who has a terminal prognosis.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for home care - nursing, nursing - home care - licensed practical nurse (LPN) per hour increase to 84 hour(s) per week services is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Stelara 90MG (milligrams)/ML (milliliters) Syringe (every 6 weeks).
The insurer denied: Stelara 90MG (milligrams)/ML (milliliters) Syringe (every 6 weeks).
The denial is overturned.

This is an adult female. She has been diagnosed with Crohn's disease. She has been treated with Stelara 90 milligram every 8 weeks. The patient started to have symptoms 2 weeks prior to the next injection. Her doctor requested to increase dosing to 90 milligram every 6 weeks. The prior denial reason was that the requested dosing exceeded quantity limit and is greater than FDA (Food Drug Administration) labelling recommendations. 
The reason for appeal is that the patient has been on Stelara, and dose escalation is indicated. 

The health plan should cover the proposed treatment. 

A multicentre retrospective cohort study included 142 active Crohn's disease patients who received standard dosing of ustekinumab 90 milligram dose every 8 weeks. All enrolled patients received dose escalation by either shortening the interval between the doses to every 4 or 6 weeks. The study concluded that "Intensification of ustekinumab maintenance dosage was effective in over 50% of the patients." This strategy should be considered in patients who are nonresponsive to every 8 weeks ustekinumab maintenance dosing (1). Another multicenter study also showed that two-thirds of Crohn's patients recaptured response following treatment intensification with ustekinumab 90 milligram every 4 weeks (2). 
In summary, ustekinumab (Stelara) is effective for Crohn's disease and dose escalation up to 90 milligram every 4 weeks is recommended for patient lost response to standard dosing (1-3). 
As documented in appeal letter and clinic notes, this patient has been diagnosed with Crohn's disease since 2021. The patient has been on Stelara 90 milligram every 8 weeks. The patient 
developed symptoms 2 weeks prior to next injection. The treatment choice would be dose escalation to 90 milligram every 6 weeks, which is supported by current literature. Thus, the 
health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult male who presented to the emergency department with left sided low back flank pain and difficulty urinating. The patient had intravenous drug use (IVDU) history. Magnetic resonance image (MRI) showed an epidural abscess at L2-L3 and L4-L5. Neurosurgery recommended repeat magnetic resonance image (MRI). The patient was then admitted to the hospital for treatment. On the next day, the patient left against medical advice (AMA).

The hospital stay was medically necessary.

The patient presented with left sided low back, flank pain and difficulty urinating. Magnetic resonance image (MRI) showed an epidural abscess at L2-L3 and L4-L5. The hospital stay was required as this patient had evidence of possible cord compression due to epidural abscess; this supports the need for acute inpatient hospitalization. This patient required close monitoring and possible urgent surgery; a lower level of care was not appropriate for this type of monitoring. Therefore, this hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cardiac/Circulatory Problems/Heart Attack/Non-ST Elevation Myocardial Infarction (NSTEMI). 
Treatment: Durable Medical Equipment (DME) including wearable defibrillators/3 Month Rental of K0606-RR - LifeVest (Wearable Automatic Cardiac Defibrillator). 

The health plan denied the requested 3 Month Rental of K0606-RR - LifeVest (Wearable Automatic Cardiac Defibrillator) as not medically necessary. The health plan's determination is partially overturned. 

This man presented to the emergency department complaining of chest pain. His medical history was remarkable for hypertension, diabetes, obesity and hyperlipidemia. His serum troponin level was elevated. A cardiac catheterization showed no obstructive disease; however, the distal left anterior descending coronary artery (LAD) was small. Left ventriculogram showed a left ventricular ejection fraction (LVEF) of 30-35% with an apical wall motion abnormality. The patient was thought to have Takotsubo cardiomyopathy; dissection of the distal LAD could not be ruled out. An echocardiogram was performed and was consistent with Takotsubo cardiomyopathy. The patient was treated with guideline directed medical therapy for heart failure with a reduced ejection fraction. He was discharged with a LifeVest wearable cardioverter defibrillator (WCD). A repeat echocardiogram showed improved left ventricular systolic function and the WCD was discontinued. Per the information provided, the device was returned. 
At issue is the medical necessity for the 3 Month Rental of K0606-RR - LifeVest (Wearable Automatic Cardiac Defibrillator). 

I overturn, in part, the determination that the use of the WCD for the first 2 months was medically necessary. I uphold the determination that it was not medically necessary for a third month. 

Based on the documentation provided, the use of the wearable cardioverter defibrillator for the first 2 months was medically necessary. Use of the device for a third month was not medically necessary. 

This patient presented to the hospital with chest pain and was found to have a markedly reduced left ventricular ejection fraction, most likely due to Takotsubo cardiomyopathy. Depressed left ventricular systolic function is a risk factor for, and a powerful predictor of sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this man, with nonischemic cardiomyopathy and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with time and/or treatment, it is recommended that device implantation be delayed for at least 90 days following the initial diagnosis of nonischemic cardiomyopathy and initiation of therapy. If, after 90 days of optimal medical therapy, the LVEF remains less than or equal to 35%, ICD implantation is then recommended.