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

Diagnosis: Back Pain. 
Treatment: Percutaneous Vertebroplasty. 

The insurer denied a percutaneous vertebroplasty. The health plan's determination is upheld. 

The patient is a female who underwent a vertebroplasty of sacrum. Cement was placed into the sacrum through cannulated needles. 2.4 cc of cement was injected. She tolerated procedure well with no intraoperative complications identified. Under review is the medical necessity of percutaneous vertebroplasty of the sacrum. 

The percutaneous vertebroplasty of the sacrum is not medically necessary in this clinical scenario. As per current standard of care guidelines with respect to the medical necessity of percutaneous vertebroplasty, current indications for this procedure include progressive painful osteoporotic compression fractures without neurologic impairment that have been refractory to appropriate conservative management, pathologic compression fractures from an osteolytic primary vertebral tumor or spinal metastasis, primary malignant neoplasms of the bone or marrow, and painful vertebral osteonecrosis/Kummel disease. Symptomatic hemangioma and traumatic fractures in need of anterior stabilization prior to surgical procedures performed in the posterior elements are also indications. 
Prior to surgical intervention there must be appropriate attempts at conservative treatment. There must have significant documentation of pain occurring on a daily basis which is incapacitating and disabling and affects activities of daily living along with ambulation and normal functioning. The patient must have tried at least a 4 to 6-week period of medication, exercise/physical therapy, and/or bracing without significant relief.
As per the documentation submitted for review, this patient does not meet the surgical indications nor is there justification that the patient has met any of the conservative treatment guidelines prior to proceeding with the procedure in question. Therefore based on current standard of care guidelines, the Percutaneous Vertebroplasty is not indicated in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out stroke. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with hypertension (HTN), hyperlipidemia, non-ischemic cardiomyopathy, emphysema, and polysubstance abuse who presented with dizziness/vertigo, and fall due to loss of consciousness the day prior. He was diagnosed with likely peripheral vertigo which caused loss of consciousness and a fall, though a posterior stroke was considered. Aspirin was started, and a magnetic resonance imaging (MRI) and transthoracic echocardiogram (TTE) were ordered. 

The inpatient hospital stay was not medically necessary. The patient could have been cared for at a lower level of care. 

He presented with vertigo and loss of consciousness. A stroke was considered but ultimately excluded. He was not severely ill with no encephalopathy, hemodynamic instability or arrhythmia, respiratory distress or gas exchange abnormality, or acute kidney injury or electrolyte abnormality. This type of presentation can often be managed at a lower level of care. Given his significant underlying medical problems and concern for a stroke, observation was reasonable to ensure there was not a more serious problem (stroke, arrhythmia, acute coronary syndrome, etc) and that the patient improved. He did not need inpatient only testing, monitoring, or treatment as the severity of presentation was low and unlikely to worsen. He improved within an observation care time frame.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genetic Diseases. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Norditropin FlexPro 5MG/1.5 milliliter (ML) subcutaneous (SC) solution pen injector (SOPN). 
The denial is overturned. 

This is a male patient diagnosed with Prader Willi Syndrome (PWS). This request is for Norditropin 1 milligrams (mg) daily. As reported, he underwent genetic testing which showed abnormal methylation of 15q11.2-15q13.1 which is consistent with a diagnosis of PWS. His pubic hair was at tanner 1. His Insulin-like Growth Factor 1 (IGF1) was 76, Insulin-like growth factor binding protein 3 (IGFBP3) was 2908. His weight was 38.9 kilograms (kg). His height was 111 cm (-0.07 standard deviation score [SDS]) with height velocity over 1.4 of 4.3 cm/year (yr). His mother's height is 165.1 cm and father's height is 165.1 cm and mid parental height is 171.6 cm (-0.73 SDS).
At issue is the medical necessity of Norditropin FlexPro 5MG/1.5 milliliter (ML) subcutaneous (SC) solution pen injector (SOPN).

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

The requested health service/treatment of Norditropin FlexPro 5MG/1.5 milliliter (ML) SC SOPN is medically necessary for this patient.
Growth hormone (GH) is indicated in patients with Prader Willi Syndrome. [1-3] In addition GH improves motor and mental development in patients with Prader Willi Syndrome. It increases lean mass and improves bone mineral density. It decreases fat mass and improves energy expenditure and pulmonary function and developmental milestones. [4-9] The standard of care is that all patients with Prader-Willi Syndrome are treated with growth hormone regardless of height precisely for the developmental benefits. The patient has Prader-Willi Syndrome. The patient also has growth failure with a decline in height SDS. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Therefore, the requested health service/treatment of Norditropin FlexPro 5MG/1.5 milliliter (ML) SC SOPN is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Missing Teeth.
Treatment:  High gold content crown, tooth 3 and 4.

The insurer denied coverage for high gold content crown, tooth 3 and 4.  The denial is upheld.

Upon review of the documentation provided which includes copy of periapical and bitewing radiographs and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crowns for #3 and #4. The insurer has denied these services stating the there is no clinical/radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service, and therefore the service does not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is a copy of periapical and bitewing radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #3 or #4 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above and therefore the crowns are deemed not medically necessary.

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

High gold content crown, tooth #3 and #4 is not considered medically necessary for this patient.

The insurer's denial of coverage for high gold content crown, tooth #3 and #4 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal (GI) Bleed. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with no significant medical history. She presented to the emergency department with a week of melena and fatigue. She had been taking meloxicam for a week and ibuprofen once. Stool guaiac test was positive. Vital signs were notable for elevated blood pressure of 164/74 mm Hg. Physical examination was notable for pale conjunctiva and a soft, nontender abdomen with normal bowel sounds. Labs showed low hemoglobin of 7.7 and hematocrit of 23.1%, and elevated glucose of 262, and elevated lactate of 2.6.  Stool is guaiac positive. She was treated with intravenous pantoprazole. She was transfused with one unit of packed red blood cells. Gastroenterology consultation concluded she had anemia, and recommended intravenous proton pump inhibitor twice daily, nil per os (NPO) at midnight, esophagogastroduodenoscopy the next day, and follow-up labs including hemoglobin. 

The inpatient hospital admission was not medically necessary. 

In this case, the patient presented with anemia after recent melena. She responded appropriately to a blood transfusion and did not have ongoing gastrointestinal bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. She appropriately had an esophagogastroduodenoscopy to evaluate for sources of gastrointestinal bleeding, but no active bleeding was found, and there were no high-risk stigmata such as ulcer with visible vessel or neoplasm. All of the measures that were undertaken, including monitoring, labs, Gastroenterology consultation, proton pump inhibitor therapy, and esophagogastroduodenoscopy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature
Treatment: Nutropin AQ
The insurer denied the Nutropin AQ.
The determination is overturned.

The patient has mild autism and short stature and his height has been tracking below the 3rd percentile. His growth velocity was slow at 4.2 centimeters (cm)/year, with a predicted adult height of 62.5 inches. He stood 126.5 centimeters (cm) tall and weighed 28 kilograms (kg) (normal weight for height ratio). He had a standard deviation score (SDS) of -2.39, and he had Tanner 3 pubic hair and testes measuring 5-6 cubic centimeters (cc). Growth hormone (GH) therapy is being prescribed for treatment of idiopathic short stature with poor adult height prediciton.
The patient's brother has Crohn's disease and received GH therapy for treatment of short stature. His sister was noted to have short stature and a "small pituitary gland" on magnetic resonance imaging (MRI), bipolar disorder, and "pink Tetralogy of Fallot" and also received GH therapy for treatment of short stature.
At issue is the medical necessity of the Nutropin AQ.

Based on the information provided, the request is medically necessary.
The patient's height is more than 2 standard deviations (SDs) below the mean for age and gender, his growth velocity is slow, and his adult prediction based on the height measurement and bone age was more than 2 SDs below the mean for United States (US) adult men. A recent bone age radiograph was not provided to reassess the adult height prediction, and the case material provided did not include documentation that all other causes of short stature had been ruled out, including nutritional deficiency, malabsorption, occult systemic illness, hypogonadism, and thyroid dysfunction. Results of testing for classic GH deficiency were not provided. Additional information was requested, provided and reviewed.  Documentation was provided that all other causes of short stature have been ruled out. The patient has idiopathic short stature with a height more than 2 SDs below the mean for age and gender. The patient does meet Food and Drug Administration (FDA) criteria for treatment with GH (see references provided) to improve height potential.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female with a past medical history significant for bipolar disorder, human immunodeficiency virus (HIV), opioid abuse, Mycobacterium avium-intracellulare (MAI), and chronic obstructive pulmonary disease (COPD) who presented to the emergency department with complaints of worsening shortness of breath after she left the hospital against medical advice just a few hours before her presentation. 

It was determined that the patient presented to the hospital with COPD exacerbation. She was started on Solu-Medrol and received Ceftriaxone. Additional diagnostic tests, including sputum culture, were ordered. The patient was continued on her home regimen of HIV medications. Unfortunately, this patient decided to leave the hospital against medical advice again on the next day after the day of admission. 

The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld. 

Based on the generally accepted standards of care, the acute inpatient level of care is generally recommended for patients with severe underlying COPD, or with new or worsened signs or symptoms of COPD such as dyspnea, tachypnea, cough, sputum production. 
In this clinical case, there was no evidence that the patient had severe COPD at the baseline. She was not even on supplemental oxygen at the baseline. 
The admission at the acute inpatient level of care is also indicated for patients with COPD and high-risk active acute comorbidities such as pneumonia, dysrhythmia, heart failure, pleural effusion, pneumothorax, myopathy, rib fracture, or with new or worsened signs or symptoms of COPD. 
The admission at the acute inpatient level of care was also indicated in cases of COPD exacerbation associated with altered mental status, new worsening signs, and symptoms of COPD that persist despite observation care treatment. Other clinical indications include acute respiratory failure requiring mechanical ventilation, new onset of hypoxemia that persists despite observation care treatment, worsening of pre-existing hypoxemia, or significant hypercarbia that persists despite observation treatment. 
There was no evidence that the patient had any of the circumstances listed above. 
Furthermore, there was no mention that the patient required any planned invasive surgical or diagnostic procedures requiring acute hospitalization. 
Therefore, there is no overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care. 
The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease
Treatment: Inpatient admission

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

The patient is a female with chronic respiratory failure due to chronic obstructive pulmonary disease (COPD) on home oxygen, asthma,  diabetes, and anxiety who was brought to the hospital with worsening shortness of breath and was found to have hypoxia due to chronic obstructive pulmonary disease (COPD) exacerbation. The patient received intravenous (IV) steroids, frequent nebulizers and supplemental oxygen. The patient was admitted to the acute in-hospital level of care for the management of hypoxia. The patient was discharged home. The acute in-hospital level of care is denied due to lack of medical necessity. This denial is being appealed.

No, the proposed treatment was not medically necessary.
The patient was admitted to acute in hospital level of care for hypoxia. It was thought to be due to asthma exacerbation. The hypoxia resolved with the emergency room care. The patient did not receive any additional intravenous medications. The patient was able to speak in full sentences after emergency room care. The patient was not in any distress.  The patient was continued on home medications. The acute in-hospital level of care was not medically necessary as the patient could have been safely and effectively treated at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 
The insurer denied root canal therapy, porcelain fused to base metal (crown) and prefabricated post and core in addition to crown (posts) for tooth #06. 
The denial is overturned. 

The patient is a who presented to the office of their dental provider for evaluation and treatment of teeth # (number) 5 and 6. Included for review are previous letters of appeal and denial, periapical and bitewing radiographic images of teeth #5 and 6, panoramic radiograph, and full mouth radiographic series, and health plan language. The subject under review is the medical necessity for root canal therapy, porcelain fused to base metal (crown) and prefabricated post and core in addition to crown (posts) for tooth #6.

The health plan's determination is overturned.

The requested health service/treatment of root canal therapy, porcelain fused to base metal (crown) and prefabricated post and core in addition to crown (posts) for tooth #06 is medically necessary for this patient.

The tooth in question has a good prognosis with the requested treatment. The previous denials have been on the basis that the prognosis of the tooth is questionable and that maintenance of the tooth in relation to the entire dentition is not appropriate. The tooth in question has extensive periodontal attachment still present and there is enough tooth structure remaining to support the treatment requested to have a good prognosis.

Based on the extent of the decay, there is also a diagnosis of irreversible pulpitis. In any situation where the patient has the diagnosis of irreversible pulpitis, as long as the tooth is restorable, there is the requirement to treat the pulpitis. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of abscess, with an array of sequential systemic sequela. Hence, based on the diagnosis of irreversible pulpitis alone, the therapy of root canal therapy is indicated. Further, once the tooth has been root canal treated, it will need full coverage crown and post and core for retention. Hence, the requested treatment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Genetic Testing. 
The insurer denied nuclear encoded mitochondrial gene genomic sequence analysis panel. 

The denial is overturned. 

The patient is a premature birth female who carries the diagnosis of Turner syndrome. She was diagnosed with myasthenia gravis (MG) because of persistent ptosis (left greater than right), despite having negative acetylcholine (ACH) and muscle specific kinase (MUSK) antibodies. Because of a poor response to intravenous immunoglobulin (IVIG) and steroids, she was evaluated by a neuromuscular team to consider whether there might be other etiologies to explain her ptosis. Repetitive nerve stimulation was unremarkable, prompting her treating physicians to consider alternative diagnoses to MG: the principal diagnosis entertained given her constellation of signs was a mitochondrial myopathy. The health plan denied a request for nuclear encoded mitochondrial gene genomic analyses based on the evidence presented to them. The subject under review is whether the testing is likely to be more beneficial for the patient's condition than any standard treatment.

Based on the complex medical history of this patient, an initial diagnosis of MG was reasonable, as was the treatment plan. Disease processes are never static and can progress with different symptomatology and signs over time. For example, it is reasonable to suspect MG with ptosis, but the negative antibody studies alone could not rule out MG (Sharief et al., 2017) and while rare, MG can present as an autoimmune condition in Turner's syndrome. However, the unremarkable findings of negative repetitive nerve stimulation considerably diminish this reviewer's enthusiasm for a continued diagnosis of MG. Mitochondrial myopathies may present in a protean fashion, but whether the patient's clinical phenotype is a result of pleiotropic effects could only be determined by sequencing mitochondrial genes. Certainly, Turner syndrome has been associated with dual diagnoses, so this is an entirely reasonable next step in this patient's diagnosis.
While mitochondrial myopathies do not currently have disease-modifying therapies, continued research and the potential for therapeutic advances that target zinc finger nucleases and transcription activator-like effector nucleases, important in addressing mitochondrial mutations may be viable future options for this patient if the diagnosis of a mitochondrial myopathy is confirmed. Thus, the patient deserves to have this type of diagnostic study, particularly to inform the family of prognosis and to register for clinical trials as they become available.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Genetic Testing. 
The insurer denied nuclear encoded mitochondrial gene genomic sequence analysis panel. 

The denial is overturned. 

The patient is a premature birth female. She has been diagnosed with Turner syndrome, scoliosis, sleep apnea (status post tonsillectomy and adenoidectomy). and gastroesophageal reflux. She has a longstanding history of facial and distal arm weakness. She was diagnosed with myasthenia gravis (acetylcholine and muscle specific kinase [MUSK] antibody negative). At the time she was described as having a positive repetitive stimulation response on electromyography (EMG) testing. She has been receiving intravenous immunoglobulin (IVIG) infusions every 2 weeks and has also been treated with systemic steroids. Mestinon was of no benefit, but after 1 year she appeared to have improvement with IVIG. For the past few months, she has developed increased weakness, with bilateral ptosis, particularly of the left eye. There has been a less noticeable response to IVIG. She had inpatient hospital admission for auditory hallucinations. Her current medications include IVIG, omeprazole, Miralax for constipation, iron supplement and a progesterone patch.
There was some evidence of a non-irritative/non-inflammatory myopathy in the face and proximal arms. Given the lack of response to IVIG, he was concerned about the possibility of a mitochondrial myopathy and recommended a nuclear encoded mitochondrial genes genomic sequence analysis panel. Whether this test is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease is the issue at question in this review.

The proposed health service or treatment, Nuclear encoded mitochondrial genes genomic sequence analysis panel is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease. Although the patient has been treated for presumptive myasthenia gravis, she has had progression of symptoms, with increased weakness, particularly ptosis. She has negative antibodies to acetylcholine and MUSK and has not responded to Mestinon. She does not appear to be responding to IVIG, and recently had no evidence of neuromuscular junction dysfunction on recent EMG testing, raising the concern that she does not have myasthenia gravis but instead a mitochondrial myopathy. Mitochondrial myopathies can mimic a range of neuromuscular disorders, including myasthenia gravis. Establishing a precise diagnosis is crucial, to permit appropriate therapy in the form of dietary manipulation or pharmacotherapy.