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

Diagnosis:  Other
Treatment:  Inpatient Stay

The patient is a female with a past medical history significant for heartburn who presented to the emergency department with a chief complaint of chest tightness.  The tightness was located in the lower sternal area.  Her symptoms started approximately one week before the day of admission and were intermittent.  Chest tightness was aggravated by taking a deep breath.
Reportedly, she went to an urgent care clinic where she was diagnosed with heartburn and was started on Omeprazole.  Subsequently, she went to the urgent care clinic again where she underwent laboratory evaluation that included D-dimer.  This test was abnormal, and the patient was referred to the emergency department.

The inpatient stay was not medically necessary.  The inpatient stay was not medically necessary.  The Pulmonary Embolism Severity Index (PESI) is a risk stratification tool that predicts the 30-day outcome of patients with pulmonary embolism using 11 clinical criteria.  Based on the calculations, the patient received 33 points.  This means that the patient belonged to class I, a very low risk ( 0-1.6%) 30-day mortality group.  According to the standards of care accepted in the US (United States), patients who belong to a very low-risk mortality group should be considered appropriate candidates for outpatient management of pulmonary embolism (PE), if clinically appropriate and social factors allow for it.
The review of the medical records did not demonstrate that the patient had any obstacles for outpatient management of pulmonary embolism, including social factors.  She could have been cared for at a lower level of care.
Short admission for observation could have been considered since the patient was also admitted to rule out acute coronary syndrome.  Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.  A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Decompensated cirrhosis with ascites 

Treatment:  Inpatient hospital services

The insurer denied coverage for inpatient hospital services.  The denial is reversed. 

This patient is a male with a history of chronic obstructive pulmonary disease (COPD), as well as alcohol abuse.  This patient presented to the Emergency Department with multiple complaints that included abdominal pain with diarrhea and abdominal distention, as well as bilateral pedal edema.  The patient reported that he discontinued alcohol use about four months prior but developed nausea and a 2-week history of abdominal swelling and bilateral leg swelling.  The patient did not have any complaints of shortness of breath or chest pain.  Patient's physical examination revealed abdominal distention with ascites and fluid wave, bowel sounds were increased, and hepatosplenomegaly was palpable.  There was a hernia present at the ventral area; and patient had a 3+ pitting lower extremity edema.  Based on physician assessment, the patient likely had liver cirrhosis; and the physician needed to rule out whether the patient also had infectious colitis and/or portal colitis.  The documentation detailed the patient also had multiple hypoglycemic episodes with a fasting sugar as low as 33, and was treated with intravenous 50% dextrose administration.  As per documentation, patient's CT scan of the abdomen showed enteritis and large abdominal ascites.  The patient was recommended for admission.

Based on the review of the medical record, the patient had decompensated cirrhosis with ascites.  Patient developed worsening diarrhea that was significant enough to cause severe hypokalemia.  Since electrolyte abnormalities can precipitate hepatic encephalopathy, patient was at a very high risk for multiple organ failure and death.  Patient was immunocompromised from advanced liver disease and at risk for spontaneous bacterial peritonitis.  Literature indicates that the mortality for patients with decompensated cirrhosis with acute or chronic liver failure can exceed 50%.

Given the risk of rapid deterioration, decompensated cirrhosis patients need high level of acute care and often even need Intensive Care Unit (ICU) care for close monitoring and care.  Considering patient's decompensated cirrhosis with ascites complicated by electrolyte abnormalities associated with persistent diarrhea, patient's care could not have been managed safely and effectively at a lower level of care.  As such, the literature supports the medical necessity of this patient's hospital stay. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital services at the acute inpatient level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with maxillary and mandibular spacing.  He has approximately 7 millimeter (mm) overjet and 4 millimeter (mm) overbite.  Teeth A, B, C, M and R are still present and there are several unerupted permanent teeth, including all second molars.  There is no orthodontic diagnosis or treatment plan provided, so determination will be made on diagnostic records.  The treatment was denied due to a lack of medical necessity, and the family is appealing this decision.  At issue is the medical necessity of braces and 12 monthly visits.
The health plan's determination is upheld.  While the patient has spaces between the teeth and a significant overjet, there is no indication supplied of a functional impairment due to the position of his teeth.  Treatment of his bite at this age will lead to an extended time in braces.  There are several unerupted permanent teeth, but it appears there is enough room for them to emerge, which is likely as the patient is young.  The teeth are not so crowded that they would be prevented from erupting, which left untreated could damage the roots of other permanent teeth (1) leading to more invasive procedures.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  with a Class I occlusion, moderate maxillary crowding, mild overbite and mild overjet.  The proposed treatment is braces.  At issue is the medical necessity for braces and follow up visits.
The health plan's determination is upheld.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 with no auto qualifiers.  Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater.  The case requires a score of 26 or more for treatment to be considered medically necessary.  The malocclusion in question does not meet the criteria to be classified as handicapping, so treatment would not be considered medically necessary.  Thus, braces and follow-up visits are not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with back pain for the last one and a half years with worsening pain in the last six months. She has a history of left lumbar (L) 3/4 hemilaminectomy and microdiscectomy. She has has at least one lumbar epidural injection in the past with improvement. The patient also has undergone 8 sessions of physical therapy with worsening pain. She currently takes ibuprofen and is allergic to Morphine. The health plan's determination is upheld. The proposed health service, Intracept procedure-interosseous ablation of the basivertebral nerve, is unlikely to be more beneficial than any standard treatment or treatments for chronic low back pain. The two studies included and labeled as Document #1 and Document #2 represent a small group of patients (Document #1 225 patients and Document #2 17 patients) with a very brief follow up of only twelve months post procedure. Both studies fail to demonstrate the Intracept procedure as a long term effective treatment for chronic low back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient who, according to the office note  has a one and a half year history of lower back pain, progressively worsening over 6 months. Past medical history (PMH) is positive for a prior left L34 hemilaminectomy and discectomy. The patient had tried 8 sessions of physical therapy (PT) which made her worse, and had tried several ESIs (epidural steroid injections) without sustained relief.  The health plan's determination is upheld.   As the utility and benefit of this procedure for patients who have undergone prior lumbar surgery and/or diagnosed with FBBS has not been fully investigated and reported on, and the actual symptomatic level(s) has not been fully elucidated, this procedure cannot be considered more likely to be beneficial than current standard treatment
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient who is status post (s/p) lumbar (L) 3-4 discectomy in the past. She complains of 2 years of low back pain that is worse over the last 6 months. She has been treated with epidural steroid injection (ESI) with temporary relief. She has also received a course of physical therapy. She continues to experience progressive back pain. The health plan's determination is overturned. Intracept Intraosseous nerve ablation is Food and Drug Administration (FDA) 510(k) cleared for radiofrequency ablation of the basivertebral nerves. It has been found to be safe and effective for the treatment of back pain in patients with chronic low back pain of greater than 6 months duration with evidence of Modic changes on MRI. Studies have shown significant relief of pain that can be sustained at least 2 years. The risks of radiofrequency ablation are significantly lower than a fusion procedure and therefore would be considered more health beneficial than any standard treatment for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Advanced maternal age; prior history of miscarriage
Treatment: CGH (comparative genomic hybridization) test 

The health plan should cover the CGH test rendered.

The CGH test rendered is likely to be more beneficial.

The College and the Society for Maternal-Fetal Medicine offer the following recommendations for the use of chromosomal microarray analysis in prenatal diagnosis: 

1) In patients with a fetus with one or more major structural abnormalities identified on ultrasonographic examination and who are undergoing invasive prenatal diagnosis, chromosomal microarray analysis is recommended. This test replaces the need for fetal karyotype. 2) In patients with a structurally normal fetus undergoing invasive prenatal diagnostic testing, either fetal karyotyping or a chromosomal microarray analysis can be performed. 3) Most genetic mutations identified by chromosomal microarray analysis are not associated with increasing maternal age; therefore, the use of this test for prenatal diagnosis should not be restricted to women aged 35 years and older. 4) In cases of intrauterine fetal demise or stillbirth when further cytogenetic analysis is desired, chromosomal microarray analysis on fetal tissue (i.e., amniotic fluid, placenta, or products of conception) is recommended because of its increased likelihood of obtaining results and improved detection of causative abnormalities. 5) Limited data are available on the clinical utility of chromosomal microarray analysis to evaluate first-trimester and second-trimester pregnancy losses; therefore, this is not recommended at this time. 6) Comprehensive patient pretest and posttest genetic counseling from qualified personnel such as a genetic counselor or geneticist regarding the benefits, limitations, and results of chromosomal microarray analysis is essential. 

Chromosomal microarray analysis should not be ordered without informed consent, which should be documented in the medical record and include discussion of the potential to identify findings of uncertain significance, nonpaternity, consanguinity, and adult-onset disease. 

The patient meets criterion B, as she had CVS for advanced maternal age. Therefore, the health plan should cover the CGH test rendered.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Advanced maternal age; prior history of miscarriage
Treatment: CGH (comparative genomic hybridization) test 

The health plan should cover the CGH test.

The CGH test rendered is likely to be more beneficial.

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine endorse the use of CMA (chromosomal microarray analysis) when invasive prenatal diagnosis is performed, regardless of maternal age. 

The following statements are extracted from the Committee Opinion # 682 first published in December of 2016 and reaffirmed in 2019. [https://www.acog.org/-/media/Committee-Opinions/Committee-on-Genetics/co682.pdf?dmc=1&ts=20170705T0003145503] 
1) In a patient with a structurally normal fetus who is undergoing invasive prenatal diagnostic testing, either fetal karyotyping or a chromosomal microarray analysis can be performed. 2) Most genetic changes identified by chromosomal microarray analysis that typically are not identified on standard karyotype are not associated with increasing maternal age; therefore, the use of this test can be considered for all women, regardless of age, who undergo prenatal diagnostic testing.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Advanced maternal age; prior history of miscarriage
Treatment: CGH (comparative genomic hybridization) test 

The health plan should cover the CGH test.

The Society for Maternal and Fetal Medicine has issued an updated practice guideline for the use of microarray for prenatal diagnosis.  Based on the emerging medical literature in this area, it is now recommended that either conventional karyotype or microarray should be offered to patients desiring genetic diagnosis by invasive testing including the indication of advanced maternal age with normal ultrasound, as was the case with this patient.  The recommendation clearly states that both options should be available for the patient to choose from with appropriate counseling.  

Similarly, the American College of Obstetricians and Gynecologists issued an updated guidance on advanced genetic testing recommending that either karyotype or microarray should be offered to these patients.  

In terms of detection of clinically significant genetic abnormalities in patients with normal ultrasounds, the microarray technique is demonstrably superior to conventional karyotype or FISH in that an additional 1-1.7% more pathogenic variations were detected compared to karyotype in the Wapner NICHD study.  Results generally do not require cell culture so that results can be obtained faster, and some techniques can exclude maternal contamination.  

Therefore, based both on expert practice guidance recommendations from national professional organizations, as well as technical superiority of the test as demonstrated in the peer-reviewed literature, it should be considered standard of care and not experimental/investigational, and should be covered in this patient's case.

The CGH test rendered is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Formulary Exception
Decision: Overturned

The patient is a male who has migraine headaches.  He has failed anticonvulsants, antidepressants, and antihypertensives for migraine prevention.  Aimovig is requested and is under review.  The health plan's determination is overturned.  Aimovig (erenumab) is a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults.  The patient meets this indication.  Per Goadsby et al: "A total of 955 patients underwent randomization: 317 were assigned to the 70-mg erenumab group, 319 to the 140-mg erenumab group, and 319 to the placebo group."  "Erenumab administered subcutaneously at a monthly dose of 70 milligrams (mg) or 140 mg significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of 6 months."  The patient has failed anticonvulsants, antidepressants, and antihypertensives for migraine prevention.  There a valid scientific and medical basis for the requested treatment and evidence that the requested service is reasonably safe and effective for this individual under these circumstances.  Aimovig is appropriate and medically necessary in this unique clinical circumstance.  The formulary drug (examples: topiramate, divalproex sodium extended release, delayed release; propranolol; timolol) will not be as effective as the non-formulary drug (Aimovig).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Short stature and poor growth velocity 
Treatment:  Norditropin

The insurer denied coverage for Norditropin.  The denial is reversed. 

This patient is a male child diagnosed with short stature and poor growth velocity.  His height = 102.1 cm (-3.02 standard deviation score [SDS]) and a weight = 14.2 kg (-1.95 SDS) giving him a body mass index (BMI) = 13.62 kg/m2 (-1.77 SDS).  Mid-parental target height = 165.6 cm (-1.65 SDS).  Bone age was less at two documented chronological ages.  Growth velocity calculated from the measure when the height = 99 cm gives a value = 3.1cm/year. Lab evaluation was normal with an insulin-like growth factor-1 (IGF-1) = 46 ng/ml (-1.3 SDS).  His endocrinologist has recommended growth hormone (GH) therapy for a diagnosis of idiopathic short stature (ISS).  His insurer has denied stating that ISS is not a covered diagnosis.

The patient demonstrates short stature (height more than 2 SD below the mean and more than 1.5 SD below mid-parental target height), and growth failure (Height velocity = 3.1 cm/year).  Bone age is more than 1 year younger than chronological age and the IGF-1 is below the mean (-1.3 SDS).  These are all criteria to support use of GH therapy irrespective of GH stimulation results (1).

"Although children severely affected by growth hormone deficiency [GHD] fail GH stimulation tests, there is no doubt that some children with GHD achieve stimulated GH concentrations above the arbitrary cutoffs that have been applied." (1)  "In the absence of a good standard, it is therefore important that the clinician integrates all available data (clinical, auxological, radiological, and biochemical) when making a diagnosis." (2)  Current guidelines clearly recommend not using growth hormone stimulation testing as the sole criterion for a diagnosis (3).  Given the fact this patient clearly demonstrates growth failure consistent with a diagnosis of GH deficiency, he clinically is growth hormone deficient.

Reverse denial.  The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for the medication Norditropin for growth hormone therapy is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient is a morbidly obese woman with a history of hypertension, diabetes, hyperlipidemia and coronary artery disease.  She presented to the emergency department complaining of dyspnea, chest pain and orthopnea.  Her blood pressure was 247/149 millimeters of mercury (mmHg) with a heart rate of 104 beats/minute.  Her respiratory rate was 24/minute with a room air oxygen saturation.  On physical exam her breathing was labored with use of accessory muscles of respiration.  She had bilateral pulmonary rales and peripheral edema.  She was treated with bi-level positive airway pressure (BiPAP), nitroglycerin and intravenous furosemide.  She was admitted to the hospital for management of uncontrolled hypertension and decompensated heart failure.  An echocardiogram showed normal left ventricular systolic function and moderate diastolic dysfunction.  Cardiac catheterization was planned but postponed when the patient's blood pressure remained severely elevated.  The following day the patient was in no distress.  Her blood pressure ranged from 171-177/69-86 mmHg.  Her antihypertensive medication regimen was adjusted.  The patient had no complaints.  Her blood pressure was 158/72 mmHg.  Cardiac catheterization was performed.  This showed normal left anterior descending and left circumflex arteries.  There was a patent stent in the right coronary artery.  The patient was discharged.  Medical necessity for an inpatient admission is at issue. 

The health plan's determination is overturned, in part.

This patient presented with acute decompensated heart failure and uncontrolled hypertension.  She was tachypneic and hypoxic and required BiPAP for ventilatory support.  She was at high risk for acute respiratory decompensation and required careful monitoring at a level that could only be provided with an inpatient level of care.  However, by the second day the patient's blood pressure, while still elevated, was improved, as was her respiratory status.  Based on the records provided, there was no medical reason why the cardiac catheterization that had been postponed on the first day could not have been performed the following day, with subsequent discharge from the hospital. 

Thus, inpatient admission was medically necessary in part.  From the information provided, it appears as if the delay in performing the cardiac catheterization was due to scheduling issues over the weekend.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Oligohyramnios
 
Treatment:  Inpatient Admission 

The insurer denied the Inpatient Admission.  The denial was upheld. 

This is a female patient who presented to the Emergency Room (ER) in her third trimester of pregnancy for evaluation of oligohyramnios.  Her presenting blood pressure was 140's/70's.  The fetal heart rate was monitored that revealed a fetal heart rate of 130 with moderate variability; there were accelerations noted, but no decelerations.  External tocodynamometer monitoring was performed that demonstrated no contractions.  A pelvic exam revealed membranes were intact and nitrazine and fern tests were negative.  Intravenous (IV) fluids were administered.  External fetal monitoring, non-stress test (NST) monitoring and vital sign were monitored.  She had no contractions, and the fetal status was reassuring with Category I tracing.  The patient's preeclampsia bloodwork showed no changes from her baseline.  The biophysical profile revealed 8/8 and an amniotic fluid index 7.2.   She was deemed stable and was discharged home.

This patient had oligohydramnios.  An ultrasound did not show fetal anomalies.  The fetal heart was reactive.  There was no evidence of labor.  She could have been asked to drink lots of fluid and be followed as an outpatient with non-stress tests and biophysical profile.  The patient presented with an elevated blood pressure, no vaginal bleeding, no uterine contractions and no ruptured membranes.  There was no evidence of fetal compromise. 

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman.  So, based on this patient's presentation, she did not have preeclampsia.

According to MCG, indications for admission include:

1)  Severe preeclampsia or eclampsia, 2)  Onset of seizures, 3)  Fetal compromise, 4)  Hemodynamic instability, and 5)  Hypertension and acute end organ damage.

This patient did not have any of the above.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital service is upheld.  The medical necessity is not substantiated.