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

Orthopedic
Home Health Care

Diagnosis: osteoporosis
Treatment: Home health care
The insurer denied Personal Care Assistance Services: 24 Hours per Day (Split Shift), 7 Days per Week (Monday through Sunday), Total of 168 Hours per Week. The health plan's determination is upheld. 

The patient is a female with past medical history of osteoporosis, hypoglycemia following gastric surgery, lymphedema, venous insufficiency, cervical radiculopathy, dysthymia, thyroid nodule, neuropathy, bilateral back pain, hypersomnia with sleep apnea, coronary artery disease, chronic right shoulder pain, hypothyroidism, hypertension, and hyperlipidemia who had been assigned PCA (personal care assistant) services 24 hours/day, live- in, 7 days/week. The patient's prior assessment done via telephone, assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, bathing, and dressing lower body while extensive assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at supervision with task of bed mobility while set up with task of phone use and independent with task of eating. There was request to increase PCA services.

Personal Care Assistance Services: 24 Hours per Day (Split Shift), 7 Days per Week (Monday through Sunday), Total of 168 Hours per Week are not medically necessary for this patient.
Although the patient requires assistance with all tasks except phone use there is no documentation of overnight logs indicating the patient would need assistance with activities of daily living (ADL) such that an aid would not be able to obtain at least 5 hours of uninterrupted sleep. There are no orders or recommendations from the patient's medical provider that she needs to be turned and repositioned every 2 hours. The requested increase in PCA services without the documentation of increased care needs specifically with ADLs/ Instrumental activities of daily living (IADL) in the overnight hours would be for safety and supervision and cognitive prompting which are not covered benefits. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She presented with epigastric abdominal pain and shortness of breath.

The patient was hemodynamically stable, and had tenderness on exam. Lipase was elevated at 516 (normal 69). US (ultrasound) of the RUQ (right upper quadrant) was negative. She was hydrated and observed overnight.

On day two, the patient's lipase rose to 1914, CT (computed tomography) revealed thickening at the duodenum consistent with duodenitis or pancreatitis. She was started on a clear liquid diet.

On day three, the patient developed acidosis and was treated with bicarbonate. Her diet was advanced, and she was discharged on day four.

Yes, the Inpatient admission was medically necessary.
The patient presented with epigastric pain and was found to have acute pancreatitis, with a lipase elevated of 519 (normal 69). The lipase subsequently rose to 1914. CT (computed tomography) scan revealed thickening of the duodenum consistent with pancreatitis.

Per MCG (Milliman Care Guidelines) guidelines, inpatient hospital stay is medically necessary in patients with 2 out of 3 of abdominal pain consistent with acute pancreatitis, lipase over 3 times normal and imaging consistent with acute pancreatitis. Therefore, as the patient had acute pancreatitis with epigastric abdominal pain, lipase greater than 3 times normal and CT (computed tomography) findings consistent with acute pancreatitis, Acute inpatient hospital stay was medically necessary.

The inpatient hospital stay was medically necessary; the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Idiopathic short stature.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Nutropin AQ injection.
The denial is upheld. 

The patient is a female who has a diagnosis of idiopathic short stature (ISS). Her mother's height is 62 inches and father's height are 70 inches. Her growth chart shows that she has been growing below the chart both for height and weight.
The patient was initially evaluated in the pediatric endocrinology clinic. Her growth chart shows that her height was about 41 inches (104.1 centimeter (cm)) and weight about 33 pounds (lbs.) (15 kilograms [kg]) at that time that correspond to negative (-)2.0 and -2.4 standard deviation (SD) respectively.
Her growth was followed and treatment with Cyproheptadine was offered to stimulate her appetite because of poor weight gain; however, her mother did not start it. She underwent growth hormone (GH) stimulation testing and her peak GH was greater than (>) 10 nanograms (ng) /milliliters (ml).
At her most recent follow up visit, her height was 126.4 cm (-2.0 SD) while her weight was 21.4 kg (-2.9 SD). Based on her bone age, her adult height prediction was calculated as 58.5-59.5 inches and treatment with GH was recommended under the indication of ISS, but her health plan denied the coverage of GH under ISS.
At issue is the medical necessity of Nutropin AQ injection (Inj).

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

The requested health service/treatment of Nutropin AQ Inj is not medically necessary for this patient.
This patient is seeking GH treatment under the indication of ISS. In 2003, the US Food and Drug Administration (FDA) approved injectable somatropin (Nutropin AQ) for the treatment of ISS, also called non-GH-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 for whom diagnostic evaluation excludes other causes of short stature that should be observed or treated by other means.
This patient is quite short for her age and genetics but growing normally. Her height was about 2.0 SD below the mean for age and 1.7 SD below her genetics; however, her weight was affected more than her height and was 2.4 SD below the mean for age suggesting undernutrition (aka nutritional growth retardation) rather than ISS. She was prescribed Cyproheptadine to address undernutrition. GH is not the standard treatment for short stature associated with undernutrition.
This patient grew 22.3 cm and gained 6.4 kg in about 4.5 years which gives her a growth velocity of 5.0 cm per year. Her height continues to be at -2.0 SD while weight dropped to -2.9 SD. As this patient's height has never been 2.25 SD below the mean for age and she is growing normally, she does not meet the criteria for the diagnosis of ISS set forth by the FDA. 
Therefore, the requested health service/treatment of Nutropin AQ Inj is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a past medical history (PMH) of a seizure disorder (d/o) status/post (s/p) right temporal craniotomy and arteriovenous malformations (AVM) resection and right transverse sigmoid sinus stenting, who was admitted with c/o syncope associated with right-sided numbness/weakness. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), no focal neurologic deficits. The National Institute of Health Stroke Scale (NIHSS) was 0. Lab work was notable for coronavirus 2019 (COVID-19) positive (+). A computed tomography (CT) scan of the head showed no evidence of acute intracranial hemorrhage or acute territorial infarct. The patient was diagnosed with syncope and treated with a transthoracic echocardiogram (TTE), electroencephalogram (EEG), telemetry, biochemical work-up, and neurology consultation. Neurosurgery recommended no acute surgical intervention. Neurology noted the right-sided numbness cause was unclear and recommended outpatient follow-up. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o syncope associated with right-sided numbness. The patient did not have structural heart disease, hematocrit (HCT) less than (<) 30, shortness of breath (SOB), hypotension, or a family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, QT interval abnormalities or conduction blocks. The patient did not have a subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma, or cardiac arrest. The patient's CT scan and MRI did not show any acute intracranial abnormalities and there was no need for acute surgical intervention. The patient was diagnosed with syncope and treated with a TTE, EEG, telemetry, biochemical work-up, and neurology consultation, and these interventions could have been safely treated at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome (IBS) with Diarrhea
Treatment: Motegrity, pre-service
The insurer denied the Motegrity, pre-service
The denial is upheld.

The patient is a female with irritable bowel syndrome - constipation (IBS-C). The attending physician (AP) is requesting treatment with Motegrity.

No, the health plan should not cover the proposed Motegrity.
The patient has not failed the plan preferred Linzess and Amitiza.  There is no evidence that Motegrity is more effective or would have less adverse effects than the plan preferred Linzess and Amitiza.  Therefore, the health plan should not cover Motegrity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

This male patient, presented to the emergency department complaining of palpitations, blurred vision, and cold extremities. His blood pressure was 117/88 millimeters of mercury (mmHg) with a heart rate of 142 beats/minute. His room air oxygen saturation was 98%. His physical exam was unremarkable. An electrocardiogram showed sinus tachycardia at 123 beats/minute. There was a question of preexcitation. The patient was admitted to the hospital.
His electrocardiogram was reviewed by a cardiologist who did not feel there was evidence of preexcitation. An echocardiogram showed mild tricuspid regurgitation and was otherwise unremarkable. The patient was discharged with an ambulatory cardiac monitor.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
This patient presented with palpitations. He was hemodynamically stable. An electrocardiogram showed sinus tachycardia. Initially there was a question of preexcitation; however, a cardiologist reviewed the tracing and did not think there was evidence for this.
Palpitations can be a manifestation of a variety of cardiac arrhythmias; while most are benign, occasionally they are a manifestation of potentially serious arrhythmias. They can also be a result of non-cardiac conditions, including anxiety and panic attacks. Proper evaluation of patients with palpitations includes ruling out cardiac causes. Structural heart disease, syncope, electrocardiographic abnormalities, and a family history of sudden cardiac death in patients with palpitations are high risk features that warrant prompt evaluation, often in an inpatient setting. In low-risk patients, such as this man, outpatient ambulatory electrocardiographic monitoring is often the first step in determining the etiology for the patient's symptoms and arriving at a plan of care. This does not require a hospital admission.
Therefore, the requested health service/treatment of Inpatient Stay is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease/Other/COVID
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay. 
The health plan's determination is upheld.

At the time of his admission, the patient was a boy with COVID diagnosed (fever and cough), but recovering normally until the day prior, when he had less appetite and began vomiting. There was no new fever or breathing problems. In the emergency department (ED), the child appeared well with normal vital signs and exam, normal labs, and a normal chest x-ray. He was given an intravenous (IV) normal saline bolus and the plan was to admit him to pediatrics. There is a history and physical that documents normal vital signs and a normal exam. There is a stated plan to continue to provide IV fluid and antiemetics and monitor, but then an interval note  that day states mother and child "eloped from hospital prior to transfer to the pediatric floor."
At issue is the medical necessity for the inpatient stay.

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

No. The documentation indicates the patient never arrived on the acute inpatient unit, so no inpatient services were received. The documentation also suggests the patient did not meet admissions criteria. There was no physical or laboratory evidence of dehydration; vital signs, exam, and labs were all normal, and to whatever extent the baby was a "little dry" on arrival, despite the reportedly good urine output which had been fully managed with the IV fluid bolus. The patient did not require acute hospitalization; care had been rendered in the ED, and if there was a concern, the patient could have been monitored in the ED for a period of time before being sent home. Instead, the mother took the patient home on her own.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Comedonal Acne
Treatment: Tretinoin 0.25%  EX CREA
The insurer denied the Tretinoin 0.25% EX CREA
The denial is overturned.

The patient is a female with acne, treated with adapalene and clindamycin topicals and oral doxycycline.  Her provider is requesting Tretinoin .025% (percent) cream.

Yes, the requested Tretinoin is medically necessary.
Topical retinoids are recommended as first-line therapy for acne.  The patient has tried and failed appropriate alternatives.  Tretinoin is standard of care and is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

This patient is a male with a complex past medical history that includes gastric bypass performed for morbid obesity, sigmoid colectomy, open cholecystectomy, surgery to repair an incisional hernia, sleep apnea, hypertension, and hyperlipidemia. He presented with a recurrent massive ventral hernia with loss of abdominal domain. Thee treatment plan was for placement of a tunneled intraperitoneal catheter and daily operating room insufflation of carbon dioxide (CO2). The patient underwent open ventral hernia repair without mesh, bilateral rectus flap advancements, complex wound closure, lysis of adhesions, and removal of the previously placed dialysis catheter. He was discharged from the hospital.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

This patient had a large recurrent incisional abdominal wall hernia. He had a complex past surgical history. The submitted clinical documentation states that the patient had loss of abdominal domain and consequently progressive presurgical pneumoperitoneum (PPP) was planned as means to expand the abdominal cavity in preparation for ventral hernia repair. The patient was admitted to the hospital and underwent placement of a peritoneal dialysis catheter. He was returned to the operating room each daily and underwent insufflation of the abdomen via the peritoneal dialysis catheter under sedation anesthesia. The corresponding progress notes  document clinical stability, tolerance of diet, ability to ambulate and pain control with oral medications.
Based on the current published peer-reviewed literature it is not known to any degree of medical certainty whether or not the daily inpatient management of a patient with a large recurrent ventral hernia with PPP is medically necessary or will improve the clinical outcome. Consequently, inpatient stay is not medically necessary.
The Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society [IEHS]): Part B (Bittner) states that due to the low evidence of available data, no recommendations regarding the use of Botox A, progressive pneumoperitoneum, and tissue expanders as adjunct interventions in ventral hernia repair can be made. The references that resulted in this statement from the International Endohernia Society (IEHS): Part B are listed on pages 3534 - 3535 of Surgical Endoscopy 2019 Nov;33(11). Therefore, inpatient stay is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pediatric Crohn's Disease
Treatment: Humira 80mg once weekly
The insurer denied the Humira 80mg once weekly
The denial is upheld

The patient is a male. He has been diagnosed with Crohn's disease. He has been on Humira initially 40 mg (milligrams) every two weeks, and then 40 mg (milligrams) every week. He still has symptoms with drug level of 9.2. His doctor requested to increase Humira dosing to 80 mg (milligrams) every week.

The health plan's reason for prior denial was that the requested 80 mg (milligrams) weekly is not consistent with FDA (United States Food and Drug Administration)-approved labeling for use.

No, the Humira 80mg (milligrams) once weekly is not medically necessary.
Dubinsky et al. conducted multicenter trial of Humira weekly dosing in children with Crohn's disease. They concluded that, "Weekly adalimumab dosing was clinically beneficial for children with Crohn's disease who experienced nonresponse or flare on EOW [every-other-week] dosing. No increased safety risks were observed with weekly dosing." In this study, the Humira dose is 20 mg (milligrams) or 40 mg (milligrams) every week. The most recent published study used Humira 80 mg (milligrams) every two weeks as a high dosing regimen (Narula).

There have not been any clinical studies to use adalimumab 80 mg (milligrams) weekly in children with Crohn's disease. The current treatment guidelines or consensus do not have specific recommendation for Humira 80 mg (milligrams) weekly (1-4). Thus, the requested Humira 80 mg (milligrams) weekly is not medically necessary as supported by current peer-reviewed medical literature, clinical practice guidelines, or standard of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

There have not been any clinical studies to use adalimumab 80 mg (milligrams) weekly in children with Crohn's disease. The current treatment guidelines or consensus do not have specific recommendation for Humira 80 mg (milligrams) weekly (1-4). Thus, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chron's disease

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

The patient has Crohn's disease. She presented with nausea, vomiting, diarrhea, and high output from her ileostomy. She was hemodynamically stable. There was no abdominal rebound or guarding. A CAT (computed tomography) scan of the abdomen was negative for obstruction. Stool for Clostridium difficile toxin was negative. She was diagnosed with a flare up of her Crohn's disease. She was started on IV (intravenous) steroids and then switched to oral prednisone.

Clinical indications for admission for Inflammatory Bowel Disease (MCG (Milliman Care Guidelines) M-565) include hemodynamic instability, abdominal abscess, fistulizing Crohn's disease, intestinal perforation, intestinal obstruction peritoneal signs, severe electrolyte abnormalities, severe dehydration, severe anemia, acute renal failure, and bacteremia. The patient did not have these conditions.

This patient had an exacerbation of her Crohn's disease. She could have been given IV hydration and started on steroids as an outpatient with observation status. Afterwards, she could have been discharged on a course of oral steroids. She did not meet MCG criteria for admission for Inflammatory Bowel Disease. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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

The insurer's denial of coverage for the inpatient hospital is upheld. Medical Necessity is not substantiated.