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

Diagnosis: Metastatic melanoma. 
Treatment: J9144 injection, Daratumumab, 10 milligram (mg) And hyaluronidase - FIHJ, 6 units. 
The insurer denied coverage for J9144 injection, Daratumumab, 10 mg And hyaluronidase - FIHJ, 6 units. 
The denial is upheld. 

This is an adult male stage four (IV) metastatic melanoma, immune thrombocytopenia (ITP) from immunotherapy for melanoma, chronic lymphocytic lymphoma (CLL), and monoclonal gammopathy of undetermined significance (MGUS). The patient has tried and failed intravenous immunoglobulin (IVIG). The treating provider recommended treatment with J9144 injection, Daratumumab, 10 mg And hyaluronidase - FIHJ, six units, which is under review. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

Outside of early phase II trials, daratumumab is not supported to treat ITP.  Current guidelines on the managed of ITP do not recognize the use of daratumumab in this setting. 

Per Tsykunova, G., et al., (2022), "Treatment with daratumumab in ITP patients shows promising results and seems safe." 

Per Neunert, C. et al., (2019), "In adults with ITP lasting >=3 months who are corticosteroid-dependent or have no response to corticosteroids, the American Society of Hematology (ASH) guideline panel suggests rituximab." 

Per Vernava, I., & Schmitt, C. A. (2023), "Primary immune thrombocytopenia (ITP) in adult patients typically presents as a repeatedly relapsing disease in need of multiple lines of therapy. As the underlying mode of action, we hypothesize here daratumumab to effectively target long-lived plasma cells as the source of ITP-mediating autoantibodies and suggest broader clinical evaluation of daratumumab in this potential indication. Trial registration: ClinicalTrials.gov NCT03129828." 

The requested service does not have final approval from the appropriate regulatory bodies for this diagnosis. 

Daratumumab does not have approval for this diagnosis. 
   
This patient is not a good candidate for the requested service. 

Daratumumab does not meet accepted criteria for the patient's diagnosis.   

It is not the best available treatment for this patient at this time and does not have approval for the patient's diagnosis. 

The requested use of daratumumab is experimental to treat ITP. There is no literature to support it would be more beneficial as compared to standard treatments for ITP. 

In summary, the denial of J9144 injection, Daratumumab, 10 milligrams (mg) And hyaluronidase - FIHJ, 6 units should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

This is a male patient with chest pain and an abnormal outpatient stress test. He underwent a cardiac catheterization and stenting of left anterior descending (LAD) and diagonal bifurcation stenosis. The creatinine was normal. There were no complications and he remained stable. At issue is the medical necessity of an inpatient stay.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care toward percutaneous catheterization or overall cardiac outcomes. It is therefore not considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II subdivision right malocclusion 
Treatment: Comprehensive Orthodontic Treatment and Monthly Visits
The insurer denied Comprehensive Orthodontic Treatment and Monthly Visits. 
The health plan's determination is overturned. 

The patient in question is a female with a Class II subdivision right malocclusion and anterior crossbite of tooth #6. Tooth #27 is erupted to the labial and has gingival recession. She is treatment planned Comprehensive Orthodontic Treatment and Monthly Visits. 

Comprehensive Orthodontic Treatment and Monthly Visits are medically necessary for this patient.
The patient has significant maxillary anterior crowding with tooth #6 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #27 already has recession, and further labial movement of #27 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident
Treatment: Personal Care Aide 7 Days x 12 Hours x 2 Shifts
The insurer denied Personal Care Aide 7 Days x 12 Hours x 2 Shifts.
The health plan's determination is overturned. 

This is a case review for a male with medical history notable for prior cerebrovascular accident and cognitive decline. The patient is approved for 12 hours per day, 7 days per week (84 hours per week) of personal care aide services. The patient and his care team requested an increase to Personal Care Aide 7 Days x 12 Hours x 2 Shifts.
A community advocate provided a letter of support for this appeal. The letter states that the patient is bed bound and needs assistance with transfers. He has incontinence and needs assistance with diaper changes. His current aides work only 12 hours per day, and when they arrive the next morning to care for him he is covered in urine and feces in bed.

The requested health service of Personal Care Aide 7 Days x 12 Hours x 2 Shifts is medically necessary for this patient.
The patient lives by himself. He is not able to direct his own care. He is incontinent of urine and stool and not able to change his diapers independently. He is not able to reposition in bed without assistance. His personal care needs can be expected to be unscheduled and continuous in nature, such that 24 hour care would be medically necessary. Failure to provide for these personal care needs could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: idiopathic short stature
Treatment: Nutropin
The insurer denied Nutropin. The health plan's determination is overturned. 

This is a female diagnosed with short stature. Under review is the use of Nutropin.

Nutropin is medically necessary.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. The Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
This patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. Therefore, she meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary. Nutropin is medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malpositioned Teeth
Treatment: Braces and monthly visits
The health plan denied: Braces and monthly visits
The determination is: Overturned

The patient is a female. She has a Class II malocclusion with crowding and protrusive maxillary incisors. She has a 7-millimeter (mm) overjet and 6-mm overbite. She has severe maxillary crowding and severe mandibular spacing. She is missing teeth 19, 24, 25, and 30. She is treatment planned for 24-30 months of orthodontics to correct the crowding, deep bite, and protrusion.
At issue is the medical necessity of braces and monthly visits.
The health plan's determination of medical necessity is overturned in whole.
The requested health treatment/service of braces and monthly visits is medically necessary for this patient. Tooth #8 is protruding forward within the dental arch. This makes it more prone to trauma. There is strong medical evidence that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.[1] Orthodontic treatment can make the teeth significantly less protrusive. If orthodontic treatment reduces the protrusion, it will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, there is scientific evidence that oral health quality of life is reduced in patients with 6-mm or greater overjets, which this patient has.[2] For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment: D8080 braces.

The insurer denied coverage for D8080 braces.

The denial is upheld.

Upon review of the submitted documentation it is evident that the patient exhibits a malocclusion. To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are include utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer score on the HLD index attains 19 points which is below the required 26 points.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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 D8080 braces is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out pneumonia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is an adult female who presented to the hospital with shortness of breath, wheezing and cough with productive green sputum for 4 days. At presentation vital signs were: Temperature 98.7 degrees F, respirations 20, Blood Pressure 157/94 and heart rate 98. Oxygen saturation was 94 % on room air. Patient was in no apparent distress and was speaking full sentences. Lung exam revealed bilateral wheezes. No edema was present, and the patient was alert and oriented to person, place and time. The white blood cell (WBC) count was 7,000, Hemoglobin 9.3, Electrolytes within normal limits, Potassium 3.2, Blood urea nitrogen (BUN)/ Creatinine (Cr) 11/0.8, B-Type Natriuretic Peptide (BNP) 49. Troponin was negative and venous blood gas (VBG) 7.43/35/56.
Chest X-ray (CXR) showed mild perihilar interstitial process consistent with volume overload/early congestive heart failure (CHF), rule out pneumonia.
The patient was treated with intravenous (IV) Steroids, Duo Nebs and Magnesium and was placed on Rocephin and Azithromycin for possible community acquired pneumonia (CAP). Patient was admitted to the hospital for Asthma Exacerbation and rule out CAP.

The patient responded to the treatment and  was feeling better, in no distress, oxygen saturation was 100 % on room air. The patient was switched to oral antibiotics.

This patient did not need acute inpatient hospitalization and was stable after admission.
Unclear if she had pneumonia. She was speaking in full sentences, not hypoxic and was tolerating oral fluids. There was no clinical evidence of congestive heart failure (CHF). No edema, no jugular vein distention (JVD), and no rales on exam. 

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Overturned

The patient is a male with chronic systolic heart failure due to ischemic cardiomyopathy, coronary artery disease (CAD) status/post (s/p) percutaneous coronary intervention (PCI), cardiac resynchronization therapy - defibrillator (CRT-D), atrial fibrillation on direct oral anticoagulation (DOAC), and ventricular tachycardia (VT) who presented to the emergency department (ED) for evaluation of worsening shortness of breath and chest pain after implantable cardioverter defibrillator (ICD) shock at home. The patient was admitted under inpatient level of care for evaluation and treatment ICD shock and rule out acute coronary syndrome (ACS). ICD interrogation demonstrated an appropriate shock for ventricular fibrillation (V-fib). Cardiology service was consulted and recommended a coronary angiogram. It demonstrated chronic total occlusion (CTO) of the distal circumflex and obtuse marginal artery (OM1) with patent right patent ductus arteriosus (PDA) stent. No additional occlusive coronary disease was detected. Electrophysiology service was also consulted recommending continuation of amiodarone and maintaining normal electrolytes levels. An echocardiogram revealed severely reduced left ventricular ejection fraction (LVEF) with inferolateral wall aneurysmal changes. The patient was subsequently discharged home in stable condition.
At issue is the medical necessity of the inpatient stay
The health plan's determination of medical necessity is overturned in whole.
Yes, the inpatient stay was medically necessary. The patient presented with a presyncopal event due to an appropriate ICD shock for V-fib; admission under inpatient level of care for device interrogation, comprehensive lab testing, telemetry monitoring, specialty consultation, and urgent ischemic evaluation was medically necessary and appropriate in this case. Furthermore, monitoring the patient under the inpatient level of care given his increased risk for recurrent ventricular arrhythmias and ICD shocks was medically necessary and best for patient safety. Additionally, the patient's HEART score was 6, indicative of increased risk for short-term major adverse cardiac events supporting inpatient level of care as recommended by American College of Cardiology (ACC)/American Heart Association (AHA) expert consensus guidelines on chest pain management and ventricular arrhythmias [1, 2]. Evaluation and management of this high-risk patient at increased risk for major adverse cardiac events (MACE) and recurrent ventricular arrhythmias would not have been medically appropriate nor safe under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult with end stage renal disease on hemodialysis admitted for worsening back pain after a fall. The patient was evaluated by nephrology and underwent routine dialysis. The patient was also evaluated and treated by physical therapy for back pain. Due to poorly controlled blood pressure, anti-hypertensive regimen was adjusted, and blood pressure was monitored. The patient was discharged in stable condition. The patient's condition could have been treated safely under a lower level of care per evidence-based literature.

An evidence-based specialty society guideline concludes that adult patients with severe hypertension (such as systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120) without acute or worsening target organ damage (sometimes deemed a hypertensive urgency) can be treated with oral medication, and do not require inpatient care [1].

Database analysis of a cohort of 552,569 patients (mean age 58 years) discharged from an emergency department with a primary diagnosis of hypertension found that in the weeks after discharge the rate of intracerebral hemorrhage was exceedingly low (less than 0.02%), and not elevated to a statistically significant degree compared to the rate the same patients experienced over the same time period a year later[2] In the same analysis, among the 10,288 patients discharged with a diagnosis of malignant hypertension, the rate was similarly low (0.03%), and also not different from the same time period a year later.

A multiyear database analysis of patients seen in a Canadian emergency department with a primary diagnosis of hypertension found in the last year of the study (25,950 patients, median age 64 years) that over 92% of patients were treated without admission to inpatient care [3].

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Secondary syphilis versus endocarditis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
Patient is an adult male who is immune compromised with past medical history significant for syphilis, chlamydia, and gonorrhea who presented to the emergency department with complaints of bilateral palm, knee, and foot pain with rash to hands, and pleuritic type chest pain.

Vitals on presentation included: Temperature 97.1 degrees F, Blood Pressure 141/83, Pulse 77, Respirations 18, oxygen saturation 100% on room air. Laboratory results included the following: White blood cells (WBC) 5.1, Hemoglobin 14.8, Hematocrit 42.8, creatinine 0.88, glucose 89, lactate 1.2, d-dimer 0.65, erythrocyte sedimentation rate (ESR) 40, C reactive protein 50.71.

Patient was admitted with a possible secondary syphilis versus endocarditis. Chest x-ray was negative. Computed tomography (CT) angiogram showed bilateral tree-in-bud like branching nodularity. He was empirically started on intravenous antibiotics (penicillin). Infectious Diseases consulted. Treponemal pallidum positive, and rapid plasma reagin (RPR) titer was 1:256. Patient remained afebrile, and hemodynamically stable. He was discharged to continue management as an outpatient.

According to documentation, patient presented rash including "peeling of skin to bilateral soles of his feet and hands." Despite patient's history of syphilis, other diagnostic possibilities had to be ruled out including a systemic infection such as endocarditis in this high-risk immunocompromised patient. Moreover, d-dimer elevation and abnormalities found on CT angiogram added complexity to this presentation, warranting hospital admission.   

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low hemoglobin
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female with a history of hypertension, type 2 diabetes, diverticulosis, and anemia requiring transfusions in the past. She presented to the Emergency Department (ED) for an emergency evaluation due to hemoglobin 6.5 at urgent care. The patient noted that she was playing at home with her daughter when she checked her blood pressure and noted that it was elevated, prompting a visit to urgent care. At urgent care, hemoglobin was found to be 6.5, and she was referred to the ED for blood transfusion and further management. The patient also endorsed increased fatigue and sleepiness over the prior month with difficulty working. She reported dizziness for two days, intermittent right sided paresthesia for 3 weeks, and intermittent weakness and fatigue.

On examination, the patient had a temperature of 98.2 degrees Fahrenheit, pulse of 72, and blood pressure was normal at 121/71. She appeared in no acute distress with a regular rate and rhythm, skin was warm and dry, and she had normal bowel sounds without abdominal tenderness. Initial laboratory studies were remarkable for hemoglobin 6.6 and MCV (mean corpuscular volume) 68.7 (microcytic anemia). The patient was hyperglycemic with glucose 188 and had a low ALT (alanine aminotransferase) at 7. Fecal occult blood test was negative.

In the ED, the patient was administered two units of packed red blood cell transfusion. Upon serial monitoring, the patient had ongoing fatigue consistent with failure to achieve symptom improvement. The patient underwent EGD (esophagogastroduodenoscopy) with GI (gastroenterology), which demonstrated diffuse erythematous mucosa in the antrum and body of the stomach with erosions suggestive of erosive gastritis. Biopsies were obtained; 1cm (centimeter) ulcer was noted with minimal blood coating it and it had underlying fibrosis. GI recommended PPI (proton pump inhibitor) twice daily for 8 weeks followed by once daily.

The inpatient hospital admission was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

An inpatient level of stay was not medically necessary, as the patient did not require any surgical intervention, did not have active or ongoing gastrointestinal bleeding, did not have any procedural related complications, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.