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

Diagnosis:  Kidney Stone.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial was upheld.

This is a female patient with history of renal stones.  The patient presented to the Emergency Department (ED) for stent placement for a persistent systematic 5 mm right ureter vesical junction (UVJ) stone, which had been diagnosed about 2 weeks prior to this ED visit.  The patient's presenting vital signs were:  blood pressure of 109/56 and temperature of 98.3 F.  Laboratory work up was performed that revealed white blood cell (WBC) count of 4.65; urinalysis (U/A) was done that showed trace blood/ leukocytes.  The patient was admitted to the hospital.  She was taken to the Operating Room where she underwent a cystoscopy and right ureteral stent placement under general anesthesia.  The patient tolerated the procedure well with no complications.  The patient was discharged home later that day. 

Based on the review of the medical record and the literature, the patient fails to meet the clinical criteria for admission to inpatient care.  There was no evidence of hemodynamic instability, acute renal failure, bilateral observation, urinary tract infection (UTI), transplanted kidney with obstruction, etc.  In addition, as per the MCG Health (23rd) Urologic Surgery or procedure GRG, the patient fails to meet indications for admission to inpatient care, as this procedure is normally designated for the ambulatory surgery setting.  The patient's procedure was uncomplicated and did not present with extenuating circumstances that warranted inpatient level of care.

The inpatient hospital admission is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain. 
Treatment:  Inpatient admission. 

The insurer denied the inpatient admission.  The denial is upheld. 

No, the proposed inpatient admission was not medically necessary.

The patient is a female.   At the time of admission to the hospital, she had a past medical history significant for hypertension (HTN), dyslipidemia, and diabetes type II.  The patient was evaluated in the outpatient setting for chest pain and a nuclear stress test was performed, which revealed possible anterior-lateral ischemia.  As per medical records, the patient was referred to the hospital for an elective cardiac catheterization. 

The patient was hemodynamically stable.  The electrocardiogram (ECG) was unremarkable.  There was no evidence of troponin elevation.  The patient underwent a cardiac catheterization, which revealed no evidence of significant coronary artery disease.  She had no complications, tolerated the procedure well, and was discharged home with a plan for outpatient follow-up.

The patient presented for evaluation of chest pain.  Her outpatient stress test was abnormal, and she was referred for an elective cardiac catheterization.  The catheterization revealed no evidence of significant coronary artery disease.  There were no peri-procedural complications. The standard of care for patients post elective catheterization is ambulatory care or post-procedure observation. Usually no acute inpatient admission is required, unless there is evidence of a bleeding or ischemic complication, peri-procedural myocardial infarct (MI), hemodynamic or electric instability.  None of these complications were documented for this patient, and she was discharged home the same day.  There was no evidence of acute MI, hemodynamic instability or malignant arrhythmia.  Thus, the medical record does not support medical necessity for acute inpatient care, and the services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, Congestive Heart Failure.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient with a history of hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus. He presented to the emergency department (ED) with complaints of shortness of breath, and worsening lower extremity edema for about 2 weeks. He also reported having difficulty ambulating and some orthopnea.
The patient was admitted to the hospital for hypertension/congestive heart failure. He was treated with intravenous (IV) Lasix initially, oral blood pressure and diabetic medications. His presenting vital signs revealed blood pressure of 207/89. The patient's lung exam revealed some bilateral rales and bilateral leg edema. He was treated with labetalol. His blood pressure decreased to 169/82. Laboratory work up was performed that revealed white blood cell (WBC) of 8.8K. The electrolytes were essentially normal
BUN/ Cr 26/1.18. A chest x-ray (CXR) was done that showed some interstitial prominence, no effusions. An electrocardiogram (EKG) was done that did not reveal any acute ischemic changes; his troponin was negative. The patient had a low Wells predictive score for deep vein thrombosis (DVT) with a negative DVT study. The patient was discharged home after a period of medical stability. 

This patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient was awake, and alert, tolerating oral intake and was ambulatory. A myocardial infarction had been ruled out. The patient was not in overt heart failure, was ambulatory, and labs were stable. She did not have DVT or pulmonary embolism and oxygen saturation was 98%.

The patient was stable to be discharged home on oral meds with close follow up in outpatient setting.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with Class I occlusion, mild maxillary spacing and moderate mandibular spacing, moderate anterior open bite. The patient's molars and cuspids are in dental Class I occlusion. The cephalometric x-ray does show a tendency for a mild retrognathic/hypoplastic maxilla, but I would ultimately classify the patient as Class I occlusion. In addition, once the lower spaces are closed, then proper incisal coupling would be achieved. The proposed treatment is braces. The issue under review is the medical necessity for braces and monthly visits. 

The health plan's determination is upheld. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 17 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 and treatment would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a Class I malocclusion and anterior crossbite of tooth number (#) 7.  He is treatment planned for 24 months of orthodontics to correct his malocclusion.  At issue is the medical necessity of the requested treatment-braces, monthly visits x12, retainer.
The health plan's determination is overturned.
The braces, monthly visit x 12, retainer are medically necessary.  The patient has significant maxillary anterior crowding with #7 in crossbite.  This tooth has a high risk for restorative problems in the future due to his traumatic occlusion with the mandibular teeth.  Studies have shown that even the untreated dentition shows increased anterior irregularity with time [4], which will make treating this occlusion at a later time more difficult.  Tooth #26 already has slight recession, and further movement of #26 will likely lead to the need for future for periodontal grafting on this tooth.  Orthodontic treatment, now, will likely prevent the need for future periodontal and restorative procedures.  For these reasons the requested services are medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

This is a patient with secondary progressive multiple sclerosis.  He is currently treated with Gilenya.  Treatment with Mayzent is requested.  At issue is whether the formulary drugs will be or have been ineffective, would be as effective as the non-formulary drug (Mayzent), or would have adverse effects.  The health plan's determination is overturned.  The formulary drugs would not be effective for treatment of the patient's condition.  The patient has secondary progressive multiple sclerosis.  None of these medications have been evaluated for efficacy in the treatment of secondary progressive multiple sclerosis and are intended for the treatment of relapsing remitting multiple sclerosis.  Only Mayzent (siponimod) has been assessed in randomized controlled trials for efficacy in treatment of secondary progressive multiple sclerosis (SPMS).  Mayzent is a sphingosine 1-phosphate receptor modulator that is similar to but more selective than Gilenya.  Siponimod was approved in the United States by the Food and Drug (FDA) in March 2019 for the treatment of adults with active SPMS.  In the double-blind, randomized EXPAND trial of 1651 subjects with SPMS, oral siponimod compared with placebo reduced the risk of confirmed disability progression at three months. In addition, siponimod treatment reduced 12- and 24-month annualized relapse rates and reduced the volume of brain lesions identified by T2-weighted magnetic resonance imaging (MRI).
Appeal type: Medical necessity
Decision: Overturned in Part

Respiratory System 
Inpatient Hospital 

Diagnosis: Cough/Fever 
Treatment: Inpatient Hospital 

The insurer denied the inpatient stay. The health plan's determination is overturned in part. A 2 day stay was medically necessary. 

The patient is a male with no prior medical history who presented with 3-4 days of cough and fever that had progressed to a temperature of 104 and worsening dyspnea. He was seen at urgent care but sent from there to the emergency department. 

A 2 day stay was medically necessary. The patient presented with evidence of sepsis (fever, WBC, elevated bands, elevated lactate, imaging suggestive of pneumonia) and in respiratory distress. Although his scoring systems suggested a low risk of poor outcome (need for intensive respiratory support, vasopressors; risk of death), he was judged by multiple providers to be ill appearing and at high enough risk of decompensating that he was moved to the ICU. By the next day, he was starting to improve but was still dyspneic and hypoxemic and still needed close monitoring and antibiotics for pneumonia with risk of respiratory decompensation. However, by day 3, symptoms seem to have improved significantly, he was on RA, and he was ambulating without o2 or desaturation. From day 3 onwards, he seemed to have improved (symptoms, exam, and oxygenation), and at this point ongoing inpatient admission was not indicated as his risk was low, he was off o2, and his symptoms had improved and as such did not require close monitoring or inpatient only treatment.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Respiratory System.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied: Flovent HFA.
The denial is: Overturned in whole.

The patient is a male who had moderate to severe persistent asthma, now mild persistent asthma, recurrent sinusitis, recurrent asthma exacerbation, status/post (s/p) bronchoscopy. The patient is on Flovent 44 micrograms (mcg) inhaler twice daily (BID) and Flonase nasal spray for two years. His forced expiratory volume (FEV)/forced vital capacity (FVC) was 85. His physical exam was normal as per the latest progress notes. He had no recent hospitalization for asthma exacerbation. The treatment plan is to continue Flovent 44 mcg inhaler BID for some time and wean in the summertime if his asthma is well controlled. The treating nurse practitioner has reported that Redihaler is not appropriate because patient has been very successful in using inhaler techniques other than using breath actuated inhaler or Redihaler.

The health plan's determination is overturned in whole. 

Yes, the formulary drug will have adverse effects, which may be in form of recurrent asthma exacerbation. The patient has finally achieved asthma control with diligent use of inhaler technique, and it will be unsafe to switch to an altogether new Redihaler technique. Flovent HFA AER44 mcg would be more appropriate than the formulary drugs.
We have a patient who uses metered dose inhaler (MDI) technology for Albuterol HFA and Flovent HFA. If one of the medications is switched to a different technique, the chances of the patient being non adherent to daily asthma inhaled corticosteroids and rescue therapy is very high and can pose significant morbidities. The patient also has vocal cord paralysis and it is not studied whether Redihaler would be effective in a patient with vocal cord paralysis. The patient has demonstrated that he is comfortable with MDI/inhaler technique. The treatment team was able to step down the Flovent from 110 to 44 mcg and possibly if the MDI is continued, the patient may be able to be off from the inhaler altogether in recent future. Due to the above factors, Flovent 44 mcg 2 puffs BID is more appropriate than the formulary drugs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine
Treatment: Prescription drugs
Issue: Medical necessity of Norditropin
The health plan's determination of medical nedessity is overturned in whole. The requested Norditropin is medically necessary for this patient. 
This is a patient  diagnosed with growth hormone deficiency (GHD). The patient is on growth hormone (GH) therapy and has an ectopic posterior pituitary gland. Patient is being treated for hypothyroidism and adrenal insufficiency. Patient presented in the neonatal period with hypoglycemia and micro-penis. Patient remains on hydrocortisone, levothyroxine and Nutropin or Norditropin. Patient was found to have Morning Glory syndrome (MGS). Patient is currently receiving 150 milligrams (mg) testosterone. Bone age was 13y at chronological age (CA) 15y; and was 14y at CA 16y3m. Last documented testes were 2 ml bilaterally and pubic hair is at tanner 3.
Originally GH was 0.2 and  testes were 1 ml bilaterally and pubic hair is at tanner 1. The height velocity on therapy is reported to be 6.5 cm/yr.  Height on therapy recently was 168.8 cm (-0.66 SDS).
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2], [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity 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 SD; 3) height more than 2 SD below the mean and a height velocity over 1 yr. more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr. in children over 2 yr. of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr. or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low Insulin-like Growth Factor 1 (IGF1) or Insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10ng/ml.
This patient is a continuing therapy patient. The patient has hypopituitarism with deficiencies and 3 other hormones. The patient's height velocity recently was 6.5 cm per year. Patients with epiphyses that are closed or beginning to close height velocity is less than 2 cm per year. The fact that the patient's height velocity  is 6.5 cm per year indicates that the epiphyses are open. A bone age is not needed to show open epiphyses. Continuation of Growth hormone is consistent with generally accepted standards of medical practice.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Chronic migraine.
Treatment:  Cambia.

The insurer denied the Cambia.  The denial is overturned. 

The patient is a female with migraine headache disorder.  She has tried and failed ibuprofen, eletriptan, rizatriptan, zolmitriptan, sumatriptan/naproxen, sumatriptan, Fioricet and tramadol for abortive therapy. 

Yes, the health plan should cover the Formulary exception for Cambia. 

The patient has failed the preferred formulary agent, ibuprofen, as well as five other first-line migraine abortive agents.  Cambia is a standard of care treatment option in this clinical context.  Therefore, the health plan should cover the Formulary exception for Cambia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth hormone deficiency

Treatment: Norditropin

The insurer denied coverage for Norditropin

The denial is overturned. 

This is a female child diagnosed with growth hormone (GH) deficiency. This request is for Norditropin. Her GH stimulation test with clonidine and arginine peaked at 3.39. Her MRI ruled out a pituitary issue. Her bone age was 7 years 10 months at chronological age (CA) of 7 years 4 months, then was 8 years 9 months at CA of 8 years 6 months, and was 10 years at CA of 9 years 8 months. Her IGF1 was 224 and her IGFBP3 was 5.8. She is at Tanner stage 1. 

Her mother's height is 149.86 cm and father's height is 160.02 cm and mid parental height is 148.44 cm, which is a -2.29 standard deviation score (SDS). 

Her height at 8.491 years old was 122cm (-1.39 SDS) and at 10 years old was 127.508 cm (-1.64 SDS) with height velocity over 1 year 6 months of 3.7 cm/yr, which is -2.5 standard deviations. 

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society, the Lawson Wilkins Pediatric Endocrinology Society, and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity 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 SD below the mean; 2) height more than 1.5 standard deviations (SD) below the mid parental height SD; 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 years 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 years. 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 met height criterion 4 as height velocity over 1.5 years was more than 2 SD below the mean. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary. 

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient is the request is medically necessary as described below. 

Based on the above, the medical necessity for Norditropin is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and dizziness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He has a past medical history significant for HTN (hypertension), diabetes mellitus, dyslipidemia and non-ischemic cardiomyopathy, s/p (status post) normal cardiac catheterization one year prior. He presented to the ER for evaluation of intermittent lower left-sided chest pain and dizziness. 

The patient was hemodynamically stable. There were no signs of CHF (congestive heart failure) on physical examination. Cardiac troponin was negative. The patient was admitted for evaluation of atypical chest pain. He was seen in consultation by cardiology. No repeat ischemic work-up was planned. He was continued on his medical therapy and discharged home with a plan for outpatient follow-up in cardiology clinic. 

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF, malignant arrhythmia or hemodynamic instability. No ischemic work-up was planned, as the patient had a prior cardiac catheterization, which had revealed normal coronary arteries. He was discharged in stable condition, with continued medical therapy and a plan for outpatient follow-up. The clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skin infection.
Treatment:  Inpatient admission.
The insurer denied the inpatient admission.  The denial is overturned. 

Yes, the Inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review.  The patient has a history of asthma, gastritis, psoriasis, BPH (benign prostatic hyperplasia), and recurrent cellulitis.  He presented with erythema and LLE (lower left extremity) pain.  His presentation was also notable for confusion.

In the ER, the patient's vitals were as follows: T (temperature) - 99.2 (103.3 rectal), P (pulse) - 108, RR (respiration rate) - 22. BP (blood pressure) - 135/77. On general examination, the patient was NAD (no acute distress).  Examination of the patient's chest, CVS (cardiovascular system) and abdomen were normal. Examination of the patient's skin revealed LLE with erythema, swelling, tenderness, warmth.

The patient's labs were as follows:  WBC (white blood count) - 13.7 (high), Hg (hemoglobin) - 14.2, Hct (hematocrit) - 43.7, Plt (platelets) - 151, Na (sodium) - 132, K (potassium) - 3.6, Cl (chloride) - 96, CO2 (carbon dioxide) - 23, BUN (blood urea nitrogen) - 19, Cr (creatinine) - 0.8.

In the ER, the patient had a high fever and confusion.  He was started on IV vancomycin, and he was admitted.  Cefazolin was added, and ID (infectious disease) was consulted.  The patient improved and was discharged on PO (oral) antibiotics.

The patient met multiple indications for inpatient treatment and admission as spelled out by the Infectious Diseases Society of America (1) and standard of care:  1)  Sepsis and signs of systemic infection: high WBC count, fever, tachycardia, tachypnea, leukocytosis, and 2)  Altered mental status.

Thus, this admission was warranted, supported by standard of care and IDSA guidelines.  Failure to admit such as a patient can lead to loss of function, septic shock, or death.