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

Diagnosis: Growth Hormone Deficiency
Treatment: Genotropin
The insurer denied Genotropin.
The determination is upheld.

This is a male patient diagnosed with growth hormone deficiency (GHD). This request is for Genotropin. He is taking Norditropin 2.2 mg daily. His growth hormone (GH) stimulation test with arginine and clonidine peaked at 4.2. His height velocity on therapy is reported to be 11.64 centimeters/year (cm/yr). His Insulin-like Growth Factor 1 (IGF1) was 218 (123-497); Z-score was -0.6 standard deviations (SD).
At issue is the medical necessity of Genotropin.

The requested Genotropin is not medically necessary.
The patient did not meet height and height velocity criteria as the patient did not meet pretreatment height and height velocity criteria. 
GH stimulation testing peaked at less than 10ng/ml. His GH stimulation with arginine and clonidine peaked at 4.2.
The Pediatric Endocrine Society recommends against making a diagnosis of growth hormone deficiency based solely on failed growth hormone stimulation testing.
The patient does not meet growth hormone deficiency criteria.
The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria.
The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. The patient had a hospital admission. The patient was seen in the emergency department for back pain complaints and diagnosed with acute left-sided low back pain with left-sided sciatica. The patient had the symptoms for the prior five months and reported left ankle numbness for three days. The patient was seen by the orthopedist as an outpatient and referred to the emergency department for 
magnetic resonance imaging (MRI). There was very low concern for cauda equina. The patient's examination showed mild weakness of dorsiflexion of the toes on the left with mild numbness over the left lateral malleolus. Magnetic resonance imaging (MRI) of the lumbar spine shows a disc bulge with a central and left herniation resulting in focal severe left lateral recess stenosis and impingement of the descending left L5 nerve root. The patient had surgery for a L4-5 hemilaminectomy. The patient was evaluated on post-operative day one with mild surgical pain that was well controlled with medication. The patient denied any numbness or tingling. The patient had equal strength with plantar and dorsiflexion intact. The patient had treatment with physical therapy. The patient was evaluated on post-operative day two and had the pain well controlled. There is 3 out of 5 (3/5) strength of the left extensor halluces longus (EHL) and 4/5 strength of the left ankle dorsiflexion. There is decreased sensation in the dorsal left foot. The patient was discharged to home. This is a review for the hospital stay.

The inpatient admission was not medically necessary.

The need for the inpatient level of care has not been established. The patient was admitted to the hospital for radiculopathy, which was chronic. The patient had surgery with a discectomy, which is an outpatient procedure. This patient could have been treated on an outpatient level of care and receive the same services. Thus, there were no complications or additional diagnoses that would require an inpatient level of care for this hospital stay. Therefore, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with a history of seizures and alcohol use disorder. She was admitted to the hospital after losing consciousness and experiencing a seizure. She woke up on the floor surrounded by Emergency Medical Services (EMS) personnel, who informed her about the seizure and a tongue laceration. Despite confusion and fatigue, she managed to walk to the ambulance. The patient had a previous seizure episode a few years ago and received medical attention. She had an electroencephalogram (EEG) and short-term use of anti-epileptic medication. In the emergency department, the patient's neurologic examination including mental status was unremarkable. She received intravenous Zofran, Tylenol, and intravenous fluids. Laboratory results showed abnormal values, including elevated glucose and low hemoglobin. Imaging 
revealed no acute head or abdominal findings, but there were signs of chronic microvascular changes in the brain. An electroencephalogram came back normal. Inpatient admission was denied for not meeting level of care.

The requested health service was not medically necessary.

Inpatient admission was not medically necessary. The Milliman Care Guidelines (MCG) criteria indicate admission when one has had a seizure and is not back to baseline. In the emergency 
department, the patient's neurologic examination including mental status was unremarkable. The patient was back to her neurologic baseline per examination and could have been managed in the outpatient setting. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Distal Cusp Fracture Tooth #19. 
Treatment: Root canal (D3330) and crown (D2740) on tooth number 19 and an additional crown (D2740) on tooth number 3. 
The insurer denied coverage for root canal (D3330) and crown (D2740) on tooth number 19 and an additional crown (D2740) on tooth number 3. 
The denial is overturned. 

Based on the submitted documentation which includes copies of bitewing and periapical radiographs, intraoral clinical photographic images, email correspondence, narrative letter from the patient, copy of stipulation of class action settlement, dental treatment record and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was recommended on tooth # 19 with additional recommendation of full coverage crown restoration on this tooth in addition to tooth #3. The insurer has denied the root canal and full coverage crowns stating that the services are not medically necessary as the documentation did not demonstrate medical need to support the treatment and what is provided does not meet their medical necessity criteria. The patient is appealing the decision. 

Upon review of the clinical photographic images and radiographs, it supports the recommended treatment. Review of radiographs indicates a large distal cusp fracture #19 extending into the pulpal chamber. Endodontic therapy would be indicated, as recommended, on this tooth. Subsequently, there is ample coronal structure remaining on this tooth after the endodontic therapy for support of a crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crowns on endodontically treated teeth which would have an excellent long-term prognosis with the recommended treatment. As regards tooth #3 there is a large pre-existing failing restoration which upon removal would require full coverage crown for adequate prosthodontics replacement and restoration of function. As the clinical and radiographic findings support the recommended treatment, the root canal and crown on # 19 and full coverage crown on #3 are considered medically necessary. 

Reverse denial and approve coverage for root canal (D3330) and crown (D2740) on tooth #19 and an additional crown (D2740) on tooth #3 as medically necessary as the clinical and radiographic documentation supports these services, and these services would be a standard of care in general dental practice.

Based on the above, the insurer's denial must be reversed. 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 root canal (D3330) and crown (D2740) on tooth number 19 and an additional crown (D2740) on tooth number 3 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left periorbital cellulitis with vesicles
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This previously healthy toddler female presented with an acute onset of left periorbital cellulitis with vesicles. She was admitted for parenteral acyclovir, topical erythromycin, and clindamycin for a presumptive herpes simplex virus (HSV) infection. Her diagnostic evaluation included herpes simplex virus (HSV) and Varicella-Zoster Virus polymerase chain reactions (VZV PCRs), methicillin-resistant Staphylococcus aureus (MRSA) swab, and ophthalmology and infectious disease consultations. She was discharged home two days later on Valtrex and Keflex. The herpes simplex virus polymerase chain reaction (HSV PCR) and methicillin resistant Staphylococcus aureus (MRSA) swab tests were negative.

The requested health service was medically necessary.

Preseptal cellulitis is generally a mild condition that rarely leads to serious complications. The differential diagnosis is broad and includes more serious herpes simplex virus and Varicella-Zoster Virus infections. Ocular manifestations of herpes simplex virus include conjunctivitis and keratitis. Additionally, herpes simplex virus can cause acute retinal necrosis and uveitis. Most 
patients with herpes simplex virus keratitis will present with an acute onset of variable symptoms, including pain, visual blurring, photophobia, watery ocular discharge, and often a red eye. This child presented with eye redness, ocular swelling, and crusting around the eye. The primary team was concerned about herpes simplex virus infection and appropriately requested evaluation by infectious disease (ID) and ophthalmology, as well as complete diagnostic testing. The use of real-time polymerase chain reaction is increasingly available and has high sensitivity. However, even in such cases, a therapeutic trial of antiviral therapy is usually initiated. Treatment of eye lesions should be undertaken in consultation with an ophthalmologist. The differential diagnosis also includes ophthalmic herpes zoster. In the absence of obvious dendritic lesions, the differential diagnosis for the red eye is important to consider. Conjunctivitis 
(whether allergic or viral) is probably the most common cause of a red eye in the community setting, but several more serious conditions can also occur. Therefore, the initial evaluation, 
including an inpatient stay, was appropriate and medically necessary. In this case, the child required inpatient care due to the uncertainty of the patient's condition, and several compelling reasons justified the necessity for this level of care:
1. Essential specialized tests and procedures were required, which could not be administered within an observation care setting.
2. The patient needed continuous parenteral treatment, and ongoing assessments were essential, both of which were beyond the scope of care achievable in an observation setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with thyroid disease and anemia who initially presented to the emergency department with concerns of generalized abdominal pain and weight loss of several weeks to months duration. A CT scan of the Chest/Abdomen/Pelvis revealed multiple large metastatic masses throughout the liver of unknown primary as well nonspecific diffuse wall thickening of several small bowel loops in the right mid abdomen possibly reflecting focal enteritis. Tylenol and empiric antibiotics were administered. The patient was admitted to the hospital with an impression of abdominal pain related to likely metastatic disease and possible enteritis. The treatment plan included additional diagnostic testing, oral analgesia, empiric antibiotics, and consultations. A carcinoembryonic antigen (CEA) was markedly elevated. Gastroenterology consulted and recommended a diagnostic endoscopy. A bowel preparation was initiated. The patient was documented as comfortable, ambulatory, tolerating an oral diet, and saturating well on room air. The patient was discharged. At issue is the medical necessity of hospital admission.
Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The clinical indications for admission to inpatient care were not met. The patient did not have peritoneal signs, evaluation requiring the patient to not eat or drink for extended period (more than 24 hours), hemodynamic instability, severe pain requiring acute inpatient management, identification of etiology or finding that requires inpatient care (eg, aortic dissection, bowel perforation, bowel ischemia), signs of intestinal obstruction, suspected toxic megacolon, bacteremia, severe electrolyte abnormalities requiring inpatient care, inability to maintain oral hydration that persists after observation care treatment, or a surgery needed that cannot be performed on ambulatory basis.[2]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankle/foot injury
Treatment: Personal Care Assistance: Total of 56 Hours per Week
The insurer denied Personal Care Assistance: Total of 56 Hours per Week
The health plan's determination is overturned. 

The patient is a male with a history of congestive heart failure, diabetes mellitus type 2, hidradenitis suppurativa, hypercholesteremia, hypertension, lumbar herniated disc, neuropathy, and sleep apnea. He has recently been treated for right foot and ankle pain; an magnetic resonance imaging (MRI) showed fibrous calcaneonavicular coalition, ATFL (anterior talofibular ligament) rupture, CFL (calcaneofibular ligament) sprain, and PT (posterior tibialis) tendonitis. His symptoms did not improve with conservative treatment consisting of bracing, non-steroidal anti-inflammatory drugs (NSAIDs), and physical therapy, so his orthopedist recommended surgery.

Personal Care Assistance (PCA) services for 56 hours per week are medically necessary.
There is documentation in the Uniform Assessment System (UAS) of the patient requiring extensive assistance with tasks of walking, locomotion, and transfer toilet. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been used to calculate hours given that the patient has unscheduled and unpredictable care needs.
The patient lives alone and does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity.
Treatment: Inpatient weight loss surgery (procedure code 43644).
The insurer denied coverage for Inpatient weight loss surgery (procedure code 43644).
The denial is: Overturned.

The patient was seen for consultation for bariatric surgery as all efforts to lose weight have failed. The body mass index (BMI) of 34.4 with a weight of 79.4 kilogram (kg). The plan was a full bariatric workup, nutrition, and psychiatric referral and to return in 2 months.

The patient's weight was 76.8 kilogram (kg). The plan was to book for operating room (OR) for roux-en-Y gastric bypass (RYGB). The patient was seen again a month later where the patient's BMI was 35.7.

The patient has failed attempts at weight loss and has a medical history of morbid obesity, hypertension (HTN), hypothyroidism, hyperlipidemia, obstructive sleep apnea (OSA), and a current body mass index (BMI) of 35. The bariatric provider noted the patient is committed to weight loss seeking support from bariatric providers including the psychologist and nutritionist. The patient has participated in a multidisciplinary pre-operative weight loss program that implements the nutrition care process with attempts at a low-calorie diet and a supervised exercise program. The bariatric provider writes that the patient is classified as morbidly obese and would greatly benefit from the medical benefits and improved quality of life that weight loss surgery could provide. The patient was cleared medically and psychologically. The patient was seen by the nutritionist. The patient's BMI was noted to be 34.4. The patient was seen again for nutrition follow-up where the BMI was 36.8. 

The patient did have a sleep study that noted moderate obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 18.3 events per hour. 

Based upon the evidence provided, the reviewer disagrees with the insurer as this patient does meet the criteria for bariatric surgery given the patient's body mass index (BMI) was greater than 35 as well as the patient having the co-morbidity of obstructive sleep apnea (OSA). According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care (27th Edition) Gastric Restrictive Procedure with gastric bypass by laparoscopy ORG: S-513 (ISC).

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 weight loss surgery (procedure code 43644) to be provided on a date yet to be determined is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis. 
Treatment: Denosumab. 
The insurer denied Denosumab. 
The health plan's determination is overturned. 

The patient is a female who is being treated for osteoporosis and has been taking the medication Denosumab for several years. Prior to the initiation of Denosumab, her T-scores were -4.1 in the spine and -3.2 in the hip, indicating severe osteoporosis. Recently, the patient's T-scores have shown improvements, with the spine T-score improving to -3.7 and the hip T-score improving to -2.6. These improved T-scores suggest a positive response to Denosumab treatment. 

Denosumab is medically necessary for this patient. 
Denosumab is a medication commonly used to treat osteoporosis in postmenopausal women, as well as in men at high risk of fracture. It works by inhibiting the activity of osteoclasts, thus reducing bone resorption and increasing bone density. The improvements in T-scores seen in this patient suggest that Denosumab has been effectively addressing their osteoporosis. 

Regular monitoring of bone mineral density and T-scores is essential to assess the patient's response to treatment. The improvements observed in this review highlight the importance of continuing Denosumab therapy, as it has contributed to the progression of T-scores towards a more favorable range. 

In conclusion, the patient's T-scores have shown positive improvements while on Denosumab therapy, with the spine T-score improving from -4.1 to -3.7 and the hip T-score improving from -3.2 to -2.6. The decision to approve and continue Denosumab treatment is supported by these observations, which indicate the beneficial impact of the medication on the patient's osteoporosis condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic arthritis. 
Treatment: Taltz 80 mg (milligrams)/mL (milliliter) auto-injector. 
The insurer denied: Taltz 80 mg (milligrams)/mL (milliliter) auto-injector. 
The denial is upheld. 

This patient is an adult female with history of psoriatic arthritis. The patient has previously tried and failed conventional disease modifying antirheumatic drug (DMARD) methotrexate along with biologic disease modifying antirheumatic drug Humira and targeted synthetic disease modifying antirheumatic drug Rinvoq. The request for Taltz was initially denied due to the patient having tried and failed two of the preferred formulary alternatives including Cosentyx, Enbrel, Humira, Otezla, Simponi, Skyrizi, Stelara, or Tremfya. 

The requested health service is not medically necessary. 

The patient has a history of psoriatic arthritis and has previously tried and failed Humira and Rinvoq. The patient has not tried and failed two of the preferred formulary alternatives including Cosentyx, Enbrel, Humira, Otezla, Simponi, Skyrizi, Stelara, or Tremfya. However, the patient was recently started on Taltz samples and has clinically responded. Formulary alternative Cosentyx is also an interleukin (IL) 17 inhibitor very similar to Taltz. There are no clinical studies indicating that Taltz is more efficacious or safer than the preferred formulary alternatives. 
There is no contraindication to the use of the preferred formulary alternatives. Therefore, the requested health services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hemoptysis
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a past medical history remarkable for asthma, bronchitis, post-traumatic stress disorder (PTSD), who presented to the emergency department (ED) for a cough and hemoptysis. The review of systems was negative for additional clinical symptoms.
The physical examination was remarkable for right lower quadrant abdominal tenderness.
The patient was admitted for hemoptysis, secondary multifocal pneumonia. A computed tomography (CT) scan of the chest showed no pulmonary embolism (PE) and findings compatible with multifocal pneumonia. The patient was noted to have leukocytosis and bilateral basilar opacities. The patient was treated with intravenous (IV) Zosyn and Ceftriaxone. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was not medically necessary.
The documentation does not support an inpatient level of care. The patient was not in respiratory distress and had no evidence of hypoxemia. The patient was hemodynamically stable, and the care could have been rendered under observation level of care for monitoring of oxygenation. Inpatient level of care is not justified since there was no clear indication for ventilatory support or partial pressure of oxygen (PO2) less than (<) 60.
The patient was admitted for pneumonia with no clear evidence of sustained hypoxemia, or signs of sepsis. Based on the risk stratification of community acquired viral or bacterial pneumonia, the CURB-65 (confusion, uremia, respiratory rate, blood pressure (BP,) age greater than or equal to (>=) 65 years) and Pneumonia Severity Index predict a low mortality based on the patient's age, comorbid condition, and renal function. Therefore, the care could have been rendered at a lower level with subsequent discharge after two midnights.