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

Diagnosis:  Preterm Birth.
Treatment: Inpatient Admission.

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

This is a newborn female twin patient born premature, weighing 2275 grams.  The patient's Apgar scores were 9 and 9 at one and five minutes.  The patient was transferred to the neonatal intensive care unit (NICU) for further care.  Continuous pulse oximetry and cardiorespiratory monitoring was maintained until the patient was discharged.  The patient remained hemodynamically stable and had no signs of apnea or bradycardia.  At approximately 1 hour old, the patient's POCT glucose was < 40 mg/dL. Following initiation of enteral feeding one hour later and subsequently the patient's POCT glucoses were > 50 mg/dL; no intravenous (IV) fluids were administered.  The patient was able to maintain a normal temperature in an open crib and tolerate enteral feedings every three hours.  The patient became jaundiced, and her bilirubin levels were periodically determined with a peak of 11.8 mg/ dL at 79 hours old.  No treatment was indicated.  The patient was medically stabilized and discharged home.  

This is a late preterm newborn with increased risk of morbidity and mortality according to the American Academy of Pediatrics (AAP). According to MCG: Continuing Care: Intensity of Care Criteria 2 is for a neonate, who is not severely ill but needs more hours of nursing and medical care than normal neonates, as indicated by ALL of the following: hemodynamic stability (i.e. no respiratory distress, apnea requiring treatment (medication, stimulation) absent, toxic appearance absent, open crib, fever absent, and need for temperature support absent); care needed for mild instability or condition is indicated by apnea/bradycardia monitoring, monitoring of asymptomatic abnormalities, neonatal jaundice requiring monitoring or treatment with phototherapy, and/or supportive care needed for other instability or condition. 

Based on the review of the medical record, admission to the Neonatal Intensive Care Unit (NICU) at a Continuing Level of Care, Level 2 was appropriate.  The care that the patient needed and received exceeded those specified in the MCG: ORG: P-357, Newborn Care Routine. 

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

Based on the above, the medical necessity for inpatient admission is substantiated.  The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral L5- S1 Spondylolysis

Treatment: Injection of a substance, procedure code 62323

The insurer denied the injection of a substance, procedure code 62323. The denial was reversed. 

This was a male patient with a history of degenerative disc disease, spondylolisthesis of L5-S1 and epidural steroid injection (ESI) therapy. This patient presented to the orthopedist with complaints of lower back pain that radiated to his left lower extremity. Recommendations were made for physical therapy and pain medication. Over the next several months the patient returned to the orthopedist with continued complaints of pain. A magnetic resonance imaging (MRI) was performed that was significant for moderate degenerative disc disease at L4-S1 and a hemangioma in the S1 vertebral body. The patient reported having limitations with his activities of daily living (ADLs) due to his radicular symptoms. Recommendations were made for epidural steroidal injections.

The patient had ongoing symptomatology of back pain and radiation to his extremities for a significant length of time. The patient had documented difficulties with activities of daily living and his occupation due to his back pain. This patient's treatment with medications had not provided benefit. Literature supports that the next step for this patient's treatment would be to repeat epidural steroid injection. Direct instillation of an anti-inflammatory (steroid) may provide benefit. The patient had received an injection over one year ago which had helped. The patient had intervals where he was pain-free after the injection. Thus, it would be reasonable to try another injection which may relieve his current condition. 

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

Based on the above, the medical necessity for the preservice request for the injection of a substance, procedure code 62323 is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neck pain, chronic low back pain, and lumbar radiculopathy.
Treatment:  Lumbar spine decompression and fusion, represented by CPT codes 22558, 22857, 20936, 22853, 20931, 20930, and 22840.
The insurer denied coverage for lumbar spine decompression and fusion, represented by CPT codes 22558, 22857, 20936, 22853, 20931, 20930, and 22840.  The denial is upheld. 

The patient is a female with a history of neck pain, chronic low back pain, and lumbar radiculopathy.  She had previously undergone arthroscopy of the right shoulder and cervical discectomy and fusion, and percutaneous discectomy.  She has had 2 epidural steroid injections.  She underwent a radiofrequency ablation of the medial branch nerves on the left side at L3-4, L4-5 and L5-S1.  Her medical provider recommended an anterior total disc arthroplasty and/or lumbar fusion.  The magnetic resonance imaging (MRI) showed a stable examination with small broad-based central and right-sided disc herniation mildly compressing the thecal sac, mild to moderate diffuse facet joint hypertrophy without significant stenosis, and dextroscoliosis.  It was reported that the patient had -4/5 strength throughout the distal bilateral lower extremities.  Sensation was impaired to light touch throughout the bilateral lower extremities.  The patient had spasm and tenderness over the lumbar paravertebral musculature bilaterally, pain with flexion and extension of the lumbar spine.  A positive Faber's test and Gaenslen maneuver were noted bilaterally, as well as slump and straight leg bilaterally.  The patient had positive facet loading on the left with no clonus and a normal gait.  There was tenderness to palpation over the bilateral sacroiliac joints.

The patient has had multiple surgical procedures performed on her lumbar spine.  At this time, while she may be symptomatic, there is an absence of consistency between the subjective complaints, findings on examination, and findings on imaging.  On this basis, the requested surgery is not medically necessary.  The lumbar spine decompression and fusion, represented by CPT codes 22558, 22857, 20936, 22853, 20931, 20930, and 22840, requested by the doctor is not considered medically necessary for this patient.  The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

The carrier's denial of coverage for lumbar spine decompression and fusion, represented by CPT codes 22558, 22857, 20936, 22853, 20931, 20930, and 22840, requested is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's ileocolitis with fistula
Treatment: Humira 
The insurer is denied coverage for Humira. 
The denial reversed. 
This case involves a male who has been recently diagnosed with Crohn's ileocolitis with fistula. The patient's symptoms included constipation and abdominal pain which began with severe episodes of severe pain. The patient's computed tomography (CT) scan showed a 12 cm of terminal ileitis. The patient's magnetic resonance angiogram (MRA) later showed a small abscess and fistula with circumferential small bowel thickening and mucosal hyper-enhancement; there was nodular inflammation in the ascending colon with acute and chronic colitis on biopsy. The patient was treated with Pentasa and dicyclomine for fistulas and for Crohn's disease, as well as ciprofloxacin. Although some of his symptoms improved on this treatment regimen, the patient lost 20 pounds and continued to have pain as well as fever. The patient had a definite inflammatory mass on physical examination. The physician indicated that Pentasa or other compounds are not effective, or recommended for this patient's treatment of Crohn's disease and placed this patient at risk for disease progression and complication. The recommendation was to treat the patient with Humira.
Based on the review of the medical record and the literature, Humira is considered medically necessary to treat this patient's medical condition. The patient had fistulizing Crohn's disease. The standard of care is to start anti-tumor necrosis factor (TNF) agents as soon as possible. The patient was tried on Pentasa and antibiotics without success. The next step is starting a biologic agent either with or without other agents. There is a lot of evidence in the literature about the indication and efficacy of agents like Humira in this patient's circumstances.
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for Humira is substantiated. The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm labor

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission. 
The denial is upheld. 

The patient was a pregnant female who presented to the Emergency Department (ED) with complaints of pelvic pressure. The patient's examination revealed a cervix that was long and effaced with a fetal station of 0. The patient's fetal tracing was given a category of 1 and revealed contractions every 15 minutes. The patient was admitted to labor and delivery for preterm labor. The plan was to administer intravenous (IV) fluids at 125 milliliters per hour, keep the patient on nothing by mouth, administer 2 doses of intramuscular (IM) Betamethasone, administer 3 million units of IV Penicillin every 4 hours for an unknown Group B Streptococcus status, and continue to monitor the patient. The patient was doing well during the hospitalization.  The patient's fetal heart tracing revealed no contractions and continued to be given a category of 1. The patient was discharged in good condition with instructions to follow up with the obstetrician later in the day for a second dose of Betamethasone.

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. In this case, there was no documentation of any cervical changes. Thus, the patient was not in preterm labor. The patient could have been observed in the labor and delivery, received IV fluid and then reevaluated few hours later. If upon reevaluation, no cervical changes occurred then the patient should have been discharged home.

Based on the review of the medical record, neither the patient nor the fetus was in any danger. The patient had no bleeding or unstable vital signs. The patient's fetal heart rate was reassuring. There was no evidence of ruptured membranes. The management that this patient received during her inpatient admission could have been safely provided in a less acute setting. Once the provider ascertained that there was no evidence of preterm labor (no change in cervical status after few hours of observation), the patient could have been sent home after being hydrated.

According to the MCG guidelines for preterm labor, inpatient admission is medically indicated for one or more of the following conditions: Condition requiring premature delivery; Fetal distress or demise; Preterm prelabor rupture of membranes; Significant maternal disease; Vaginal bleeding; Complications of tocolytic treatment; Continued fetal monitoring that require inpatient care; Tocolytic therapy needed that requires inpatient care; Inability to stop preterm labor. In this case, the patient did not require inpatient level of care.

The health care 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: Vomiting and diarrhea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male twin child with medical history significant for some type of immunodeficiency (not SCID [Severe Combined Immune Deficiency] per the H&P [history and physical]) and low T-cell count, as well as asthma. He presented to the ED with five-day history of vomiting and diarrhea and one-day history of decreased intake and decreased wet diapers. 

The patient's vital signs included temperature 36.8, heart rate 142, respiratory rate 26, and 98% saturation in room air. Examination was significant for no distress, moist mucous membranes, regular heart rate and rhythm without tachycardia, clear lungs, benign abdomen, and non-focal neurologic exam. Laboratory evaluation revealed normal WBC (white blood cell) count with 28.3% lymphocytes and 56.8% neutrophils, and metabolic acidosis with CO2 (carbon dioxide) 18. GI (gastrointestinal) pathogen panel revealed presence of Norovirus and Enteroaggregative E. Coli (EAEC). Abdominal ultrasound was negative for intussusception. 

The patient was treated with normal saline bolus and a dose of Zofran, however he failed an oral challenge and continued to have diarrhea in the ED. He was admitted for ongoing management of dehydration. Admission orders included IV fluids, isolation precautions, regular diet as tolerated, and continuation of home asthma medications. 

Over the course of his hospital stay, the patient's oral intake improved, and his diarrhea lessened, allowing for weaning IV fluids. He was treated with azithromycin because of his immunocompromised state and the presence of EAEC. He remained afebrile and hemodynamically stable, prompting discharge home.

This young male child with immunodeficiency and asthma presented to the ED after a prolonged course of vomiting and diarrhea, failing an oral challenge and requiring two fluid boluses. It was reasonable and appropriate to continue monitoring his intake and output in the hospital setting. However, he was overall hemodynamically stable with no evidence of sepsis or impending circulatory collapse. He did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Idiopathic short stature.
Treatment:  Omnitrope injection (somatropin) 10mg/1.5ml.

The insurer denied the Omnitrope injection (somatropin) 10mg/1.5ml.  The denial is overturned. 

The patient is a female diagnosed with ISS (idiopathic short stature).  This request is for Omnitrope. 

As reported, the patient she has non-classical congenital adrenal hyperplasia, short stature and a significantly advanced bone age.  Her bone age advancement has caused a significant compromise in her final adult height.  She is on Hydrocortisone dose from 3.75 mg in the morning and 5 mg at bedtime.  Acne has been minimal. She has history of GERD (gastroesophageal reflux disease). 

The patient's mother's height is 149.86 cm, and her father's height is 167.64 cm.  The mid-parental height is 152.25 cm (-1.71 SDS).

Yes, the treatment with Omnitrope injection (somatropin) 10mg/1.5ml is medically necessary.

The patient has CAH (congenital adrenal hyperplasia) and a poor height prediction.  This is an off-label use of growth hormone.  There are studies showing safety and efficacy of growth hormone for children who have CAH and a poor height prediction, such as seen with this patient [10-12].  The request is consistent with generally accepted standards of medical practice, and it is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac circulatory problems/lymphedema
Treatment: Durable Medical Equipment
The insurer denied Pneumatic Compressor, Segmental Home Model with Calibrated Gradient Pressure
The denial is overturned in whole

The patient  who presents with bilateral lower extremity lymphedema and right lower extremity ulceration. The  patient presents with bilateral lower leg and truncal swelling. The patient attempted and failed conservative therapy with conventional compression as well as a non-segmented lymphedema pump without symptomatic clinical relief. 
Yes, the requested Flexitouch pump (E0652) and associated accessories (E0667 or E0669) are medically necessary for treatment of his condition based on the peer reviewed literature and the current standard of care in the vascular surgery community.
This particular patient is a good candidate for the requested pneumatic compression device. He has failed conservative and alternative therapies. The peer reviewed literature supports the use of the pneumatic compression pump for this patient. This particular patient is a good candidate for the requested compression pump and accessories. There is sufficient published, peer-reviewed data from well-constructed clinical trials to permit scientific conclusion regarding the lasting benefit to health outcomes from the use of the requested compression pump for treating lymphedema of the extremity and trunk as requested for this patient.
There are several high-quality publications supporting the use of lymphedema pumps for refractory lymphedema as demonstrated by this patient.
Fife and colleagues demonstrated superior results with advanced programmable pneumatic compression devices (APCD) compared with standard pneumatic compression devices (SPCD) in their 2012 study. In their outcomes, they demonstrated that the APCD-treated group experienced an average of 29% reduction in edema compared to a 16% increase in the SPCD group. Mean changes in TDC values were a 5.8% reduction for the APCD group and a 1.9% increase for the SPCD group.
Fife and Carter reviewed the benefits of lymphedema treatment in the morbidly obese and demonstrated that the condition is a clear risk factor for lymphedema, thus creating a feedback loop in these patients. In their review article, they noted that the presence of lymphedema increases the risk of becoming morbidly obese. They also noted that pneumatic compression pumps can be highly beneficial in obese patients, particularly for decompressing areas which cannot be bandaged appropriately.
Therefore, Flexitouch pump (E0652) and associated accessories for treatment of the  condition are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is previously healthy female who presented to the emergency department (ED) with right upper abdominal pain, nausea and vomiting. This symptom has been recurring and worsening over 4 months. She was hemodynamically stable at the time of presentation. She was tender in the epigastrium. The white blood cell (WBC) count was elevated at 15.37 thousand (K). Ultrasound identified gallstones and a sonographic Murphy's sign. The complete metabolic panel identified normal serum transaminases. Bilirubin was normal. She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The patient underwent laparoscopic cholecystectomy. The operative dictation and the anesthetic record indicates an uncomplicated cholecystectomy procedure.
She tolerated surgery without incident. She was monitored overnight with provision of pain medications, antiemetics, and perioperative antibiotics. Vitals remained normal and the diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.

Inpatient stay was not medically necessary in this case. This patient presented to the hospital ED with right upper abdominal pain, nausea and vomiting. Her evaluation included ED assessment, lab data, imaging, and surgical consultations. The evaluation identified gallstones and normal serum chemistries. She was hemodynamically stable at the time of presentation. Cholecystectomy was indicated based on the ED evaluation. The WBC count was elevated at the time of presentation, but promptly normalized and serum chemistries identified normal bilirubin and transaminases. Ultrasound showed gallstones. The patient underwent an uncomplicated cholecystectomy procedure. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation or in the peri-operative period.
There is no documentation of failure to achieve discharge criteria, performance of surgery, care for comorbidities that required inpatient care, procedural complications, or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer 
Treatment: Stereotactic Radiation Therapy 

The insurer denied Stereotactic Radiation Therapy. The determination is upheld.

The patient has a history of bilateral mastectomies and reconstruction and now has a medial right breast mass that was removed and revealed by pathology to be a duct carcinoma in situ with close surgical margins. The right (R) breast implant was removed and an expander placed. Radiation therapy to the right breast surgical bed is recommended and stereotactic body radiation therapy (SBRT) with hypofractionation is recommended to deliver 30 Gy in five fractions and is under review for medical necessity.

The requested health service/treatment of SBRT is not medically necessary for this patient. The recommended SBRT with hypofractionation for this patient with recurrent duct carcinoma in situ post resection is not considered a medically appropriate nor necessary approach of treatment for this patient. There are lack of any significant studies published in peer reviewed journals supporting the efficacy and safety of this approach of treatment for this clinical scenario. More significant randomized trials are needed to be performed and published in peer reviewed journals to determine the benefit and safety profile of this approach of treatment for localized breast carcinomas. The recommended SBRT would also not be medically appropriate nor necessary as many ductal carcinoma in situ (DCIS) recurrences occur in different quadrants of the breast other than the primary site of disease. Standard of care treatment for patients, such as this patient, would be whole breast radiation with a 3 dimensional (D) conformal approach to the right breast.