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

Diagnosis: Growth hormone deficiency
Treatment: Growth hormone therapy
The insurer denied Nutropin AQ. That denial was upheld

This patient diagnosed has growth hormone deficiency (GHD). He started growth hormone (GH) therapy in 2019. His GH stimulation test in 2018 with clonidine and arginine peaked at 0.8 and 1.3 respectively. His IGF1 was 121 (187-599). His bone age in late 2018 was 14 years at chronological age (CA) 14 years 1 month. His pre-treatment height on in late 2017 at 13.08 years old was 150.2 cm (-0.79 SDS) and in 2018 at 14.08 years old was 154.4 cm (-1.19 SDS) with height velocity over 1 year of 4.2 cm/yr. His height on therapy in 2019 at 14.33 years old was 159.8 cm (-0.75 SDS). His mid parental height was 174 cm (-0.40 SDS). His MRI was normal. Height velocity over 3 months prior to initiation of growth hormone was 6.5 cm per year.

Classic GH deficiency criteria are outlined in the referenced guidelines . The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 standard deviation (sd) below the mean; 2) height more than 1.5 sd below the mid-parental height; 3) height more than 2 sd below the mean and a height velocity over 1 year more than 1 sd below the mean for chronological age, or a decrease in height sd of more than 0.5 over 1 year in children over 2 year of age; 4) in the absence of short stature, a height velocity more than 2 sd below the mean over 1 year or more than 1.5 sd sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml. This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml. The patient did not meet auxological criteria as pre-treatment height and height velocity are normal. The pediatric endocrine society recommends against making a diagnosis of growth hormone deficiency based solely on failed growth hormone stimulation testing.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height 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." The patient does not have a pre-treatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria.
Appeal type: Experimental/Investigational
Decision: Upheld

This male patient has been diagnosed with medically refractory gastroesophageal reflux disease (GERD). The patient has failed acid reducing therapy with proton pump inhibitors (PPIs). The patient has had upper endoscopy which revealed LA Grade A reflux with a medium sized hiatal hernia and gastric polyps. The patient has been requested to undergo the Stretta Procedure. The health plan"s determination is upheld. No, the proposed health service or treatment, Stretta Procedure, is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Specifically, the current scientific peer review literature does show that this service improves patient clinical outcomes, however, the duration of improvement is brief with effects that diminish over time.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient is a male (body mass index (BMI) 27 kg/m2) with an 18-year history of gastro-esophageal reflux disease. His symptoms include primarily heartburn. The patient has been treated with lifestyle modification and proton pump inhibitor (PPI) therapy without complete resolution of symptoms. The health plan's determination is overturned. The Stretta is not experimental or investigational based on Food and Drug Administration (FDA) approval and the extensive body of peer-reviewed literature. This therapy is likely to be more beneficial than other standard treatment for the insured's life threatening or disabling condition or disease. Peer-reviewed literature provides adequate support for the Stretta procedure such that The Society of American Gastrointestinal Endoscopic Surgeons has drafted a position statement in support of the Stretta procedure for properly selected patients as in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient is a non-obese male with long standing gastroesophageal reflux disease (GERD) refractory to Nexium 20 milligrams (mg) daily. A 24-hour potential hydrogen (pH) was positive for significant acid and total reflux. Manometry revealed some ineffective motility. The subject for review is whether the proposed Stretta procedure is beneficial in the treatment of this patient's condition. The health plan's determination is upheld. This patient has long standing medically refractory GERD. Although a hiatal hernia was not visualized on UGI, and is sometimes missed, a medium sized hiatal hernia was seen and documented on upper endoscopy. In addition, the patient was found to have severe acid and total reflux episodes on the 24-hour pH study. Given the severity of the GERD and findings of a medium sized hiatal hernia (generally representing a >2-4 cm hiatal hernia) which would be larger than a small (1-2 cm hiatal hernia) the effectiveness of Stretta procedure for this patient may not be optimal. These are considerations for general exclusions from Stretta given the reduced efficacy and lack of published effectiveness and durability for patients with medium sized hernia.
Appeal type: Medical necessity
Decision: Upheld

The patient has type 2 diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, aortic valve replacement, and obstructive sleep apnea; the patient presented to the emergency department (ED) with hematuria and L (left) flank pain, as well as diarrhea.

The health plan's determination is upheld.  The Inpatient Hospital Admission is not medically necessary for this patient.  The patient had no hemodynamic instability, and no active bleeding was noted.  His Hgb was stable, and he had no severe anemia.  He required no urgent procedures. The record shows the patient reported gross hematuria, but when a foley catheter was placed, no active bleeding was noted.  The Hgb was stable overnight, and no gross hematuria was noted that would require continuous bladder irrigation.  The serum creatinine increased overnight, but the patient had no significant acute kidney failure requiring inpatient care.  The patient had normal vital signs and had no severe electrolyte abnormalities, severe pain requiring inpatient care, cardiac arrhythmias, or other condition that could only be safely managed at the inpatient level of care.  Inpatient care is not consistent with accepted standards of medical practice for his condition and is, therefore, considered not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The patient had significantly elevated blood pressures on presentation, but the blood pressure had improved by the time of admission after antihypertensive agent administration in the emergency department.  The patient's chest pain was not accompanied by evidence of acute coronary syndrome; cardiac enzymes were negative, and the electrocardiogram showed sinus rhythm without acute ischemic changes.  The patient did not have hyperkalemia, uremia, acidosis, or florid pulmonary edema.  The oxygen saturation was 95% on room air and the chest x-ray demonstrated only mild vascular congestion.  The patient tolerated hemodialysis without complication.  The blood pressure improved with ultrafiltration at dialysis and provision of oral antihypertensive agents.  The patient's mild degree of leukocytosis was not accompanied by fever or evidence of active infection.  
In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the member in making its determination.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a class II malocclusion, moderate maxillary crowding, mild mandibular crowding. He has an anterior crossbite at tooth number (#) 10 and a labially-ectopically erupting tooth #6. 

The health plan's determination of medical necessity is upheld. The requested service/treatment of braces is not medically necessary. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would therefore not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 23 with no auto qualifier present. Most programs using these evaluation methods require a score of 26 or more for treatment to be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized anxiety disorder
Treatment: Standard Weekly Outpatient Visits
The weekly outpatient visits are medically necessary.
The patient has a complex mental illness that is exacerbated by her complicated medical condition.  The patient has ongoing symptoms of anxiety that are impairing her functioning and it is noted by her psychologist and her dermatology team that weekly treatment is medically necessary.  The patient is receiving an evidence-based treatment modality by a licensed psychologist and is engaged in treatment and benefiting from this treatment.  Stopping this treatment would lead to a decrease in functioning, per the judgement of the patient's treatment provider; therefore, the treatment is medically necessary and should be covered in an ongoing fashion.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary biliary cirrhosis; portal hypertension; GE varices
Treatment: Inpatient admission
The Inpatient admission was medically necessary for this patient's medical condition.  
The patient was at risk for life threatening GI (gastrointestinal) bleed secondary to her large varices.  TIPS with gastric variceal embolization is standard of practice for patients with same or similar medical conditions as this patient has.
This procedure has not insignificant morbidity and potential mortality, which is why these patients are admitted to the hospital for observation as a standard of practice after the procedure in case hemorrhage or infection needs to be treated immediately.  The hospital admission is usually brief, depending on the patient's medical condition, but it is in the best interest of the patient to be observed in the hospital, where there is continual observation of the patient to ensure there are no adverse events in the immediate post-operative period.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history significant for fibromyalgia and asthma who presented to the emergency department with complaints of shortness of breath. She was admitted for observation at the Clinical Decision Unit (CDU) one day before the day of admission for an asthma exacerbation.She was discharged from the hospital, and when she arrived home she was still feeling short of breath. In addition, the patient complained of nasal congestion, myalgias, and a cough productive of a small amount of yellow mucus. The health plan's determination of medical necessity is overturned.  
The review of the medical records demonstrated that an inpatient level of care was medically necessary since she continued to have an acute flare-up of asthma, which was not adequately treated at observation level of care as well as at home. Inpatient level of care was appropriate to ensure proper administration of medications and adjustment of treatment based on the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient had widely metastatic colon cancer. She had recently had resection of a lung metastasis 14 days prior to her presenting with abdominal pain and having vomited x 4. She was not dehydrated by labs; she had no vomiting in the emergency room or after. 

There was no evidence of dehydration on the patient's exam or labs. She had no evidence of intestinal obstruction on CT scan. Her vomiting was rapidly controlled with anti-emetics. She did not require admission for nausea and vomiting.

The patient's abdominal pain was readily managed with analgesics, so well so that she refused continued admission on hospital day 1.  She did not require admission for abdominal pain.

The letter of appeal comments that her potassium was initially measured to be high at 6.3. The letter fails to mention that the specimen was hemolyzed and recheck of potassium on a venous blood gas was normal. There was no hyperkalemia. She did not require admission for electrolyte abnormalities. 

The patient had a new, small, liver nodule. Workup of progressive cancer does not in itself require acute inpatient admission. 

None of the documented problems required acute inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a chief complaint of right lower leg redness, swelling, and worsening pain. Her symptoms started three days prior to presentation. She was seen by her primary care physician and was started on Keflex without improvement. She then presented to urgent care and was changed to Bactrim. She did not notice any improvement and felt that the lesions were increasing in size and redness. She denied fevers, chills, recent illness, and sick contacts. On physical examination, she was alert and oriented, cranial nerves were intact, and there was a 10 centimeter (cm) x 5 cm area in the right lower extremity that was warm and tender with superficial blisters. The health plan's determination of medical necessity is overturned. There was initially concern for necrotizing fasciitis and she ultimately needed a course of IV antibiotics, with the infectious disease service believing that oral antibiotics were not appropriate. Cellulitis does not routinely require inpatient level of care but this patient had more complex features with a concern that she would develop necrotizing fasciitis. In addition she met sepsis criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Fever
Treatment: Inpatient admission
The inpatient admission was medically necessary. 

The patient is a young male child with medical history significant for prematurity born at 32 weeks' gestation, HbSS (sickle cell) disease, some type of brain cyst, and developmental delay. He presented to the ED with fever and vomiting. Three days prior to admission, he had low-grade fever to 100 with one episode of vomiting. Two day prior, he spiked to 103, treated with ibuprofen. One day prior to admission, he again spiked to 103 and was taken to the pediatrician, where he was presumptively diagnosed with influenza and prescribed Tamiflu. On the day of admission, he spiked to 105, treated with ibuprofen. He also had an episode of emesis. The family contacted the Hematology office, and they were told to go the ED. 

The patient's review of systems included good intake for fluids, but he was not taking solids well, no diarrhea, and no abdominal pain. In the ED, vital signs included temperature 100, heart rate 124, respiratory rate 26, and blood pressure 100/62. Examination revealed no acute distress, clear ears and throat, clear lungs, regular heart rate and rhythm, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was significant for WBC (white blood count) 13.6K with 42% neutrophils, hemoglobin 9.7, 1+ sickle cells, and negative viral panel. Chest x-ray revealed mild cardiomegaly but no focal pneumonia. 

After discussion with Hematology, the patient was given a dose of ceftriaxone and admitted for further observation. Admission orders included ceftriaxone, continuation of home medications (penicillin, hydroxyurea), Tylenol as needed, regular diet, and follow-up of blood culture. He continued to have fevers, with maximum 103.5. He also had several episodes of emesis treated with Zofran and prompting IV (intravenous) fluids administered at half-maintenance. His last temperature spike was 101.5 at 0530 hours the day after arriving. He was afebrile thereafter. Blood culture remained negative, and the influenza swab from the pediatrician's office was also negative. He had no further vomiting, and had improved oral intake by the second hospital day. He was deemed stable for discharge two days later to follow-up with Hematology in two months and his pediatrician in two days. 
This young male child with HbSS disease presented to the ED with high spiking fevers. Viral panel was negative, and chest x-ray was negative. He had several episodes of vomiting, but no diarrhea and no cold symptoms. Because of the relative immunocompromised state of patients with HbSS disease, serious bacterial infection must be considered with acute febrile illness, as in this case. Ultimately, both blood culture and influenza swab were negative and this child improved sufficiently to discharge home. It was medically necessary and appropriate to monitor him in the hospital on antibiotics pending culture results. Acute inpatient admission is consistent with his presentation, history, and the current standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Painful breast implants
Issue under review: 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk, 19371 - Periprosthetic capsulectomy, breast

Determination: 
The surgery is not medically necessary.

The patient has periprosthetic capsular contracture, which is a known complication of breast implants.  A study by Dancey et al found a 26.9% incidence of capsular contracture following breast augmentation surgery.  The original procedure was for cosmetic purposes.  Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated.  
The standard of care indicates that when implants are placed for reconstructive purposes, then treatment of these complications should be a covered service. However, in this case, the initial procedure of breast augmentation was a strictly a cosmetic procedure.  Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer.   The ASPS position paper goes on to say that insurance carriers, "respond thoughtfully and with compassion on an individual basis," for several other conditions, including, "mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography)." 
Capsular contracture is a benign condition. Although contractures can be painful, they do not pose a health risk or danger.  The surgeon's note indicate that her breasts are soft and, based on this description and the photos, she does not have Baker IV capsular contracture.  Surgery will make the patient more comfortable and will improve the appearance of her breasts, but it is not necessary to prevent a disease or illness or to treat a functional problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unilateral Primary Osteoarthritis (right knee)
Treatment: Euflexxa Intra-Articular Hyaluronan Injections To The Right Knee

Summary:
The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery.  However, the recommendations for use of Viscosupplementation have changed. 

A review of the Clinical Practice Guideline by (CPG) AAOS cites:

The 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.)

The Orthopedic group reports "strongly do not recommend use".
Appeal type: Experimental/Investigational
Decision: Overturned

This patient has history of diarrhea, abdominal pain and failure to thrive. The patient  has a stool calprotectin test to assess for bowel inflammation.
The subject under review is the calprotectin test performed in this case.
The health plans determination is overturned in whole. The use of fecal calprotectin in evaluation in patients with chronic abdominal pain is appropriate and within the standards of care. The clinical utility of this test is well supported by many peer-reviewed literature reports. It is considered standard of care is in the  gastroenterology professional community.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient with short stature, abdominal pain and loose stools. The patient has had celiac testing, complete blood count (CBC), comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR) and calprotectin as part of the  workup. The calprotectin testing was ordered as a fecal marker of inflammation.
The subject under review is the proposed fecal calprotectin testing.The
health plan's determination is overturned in whole. This is a marker of intestinal inflammation that is noninvasive. This test is used frequently by gastroenterologists to evaluate inflammation without proceeding to colonoscopy. This test is safer than colonoscopy to evaluate for inflammation and could save the patient from risks of an unnecessary procedure.
the health plans determination.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient  who was seen by his physician for concerns of failure to thrive (body mass index (BMI) 3rd percentile) with a history of loose stools and abdominal pain. The physician was concerned about possible Crohn's disease and ordered fecal calprotectin as a screening test for this inflammatory bowel disease. The test result came back normal.
The subject under review is the proposed fecal calprotectin testing in this case.The health plans determination is overturned in whole. 
Fecal calprotectin is well-established as the preferred screening test when inflammatory bowel disease is suspected. In this case, the underweight status, loose stools, and abdominal pain of the member certainly raise suspicion of IBD, and this test was clearly appropriate. Fecal calprotectin measurement is in wide use and standard of care for this purpose.