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

Diagnosis: Idiopathic Short Stature
Treatment: Nutropin AQ Nuspin 5MG/2ML (milligrams per milliliter) Pen Injctr (injector)
The insurer denied the Nutropin AQ Nuspin 5MG/2ML Pen Injctr.
The denial is upheld.

The patient is a female, small for gestational age (SGA) (body weight was four pounds, two ounces) but caught up by age three. The patient's height was 113.6 centimeters (cm) (- [negative] 3.32 standard deviations scores [SDS]). Approximately the following year, the patient's height was 114.7 cm, and approximately another year later, her height was 124.26 cm. Growth velocity (GV) would calculate to 4.6 cm per year (cm/year). Over approximately a year span, the patient's height was four feet and 0.74 inches and then height was four feet and one inch yielding a growth velocity of 1.77, or 4.3 cm/year. A clonidine test had peaked of 15.9 (greater than ten) at 60 minutes and 18.9 at 150 minutes, normal. 

The patient has been labeled as having precocious puberty and Lupron was prescribed; however, the note says that the patient was Tanner Stage 1 (prepubertal). The patient's mother's height is five feet, four inches and the patient's father's height is five feet, ten inches. Her insulin-like growth factor one (IGF-1) was 143 (76-548) and the growth hormone (GH) stimulation test was normal as noted above.

Yes, the medical records and accompanying information were sufficient.

However, growth charts, other labs (eg [for example], thyroid studies, etc [and the rest]), other studies (eg, bone age, and magnetic resonance image [MRI] of the pituitary, etc) are missing to validate idiopathic short stature (ISS). The clonidine GH stimulation test was adequate to rule out growth hormone deficiency (GHD). Supplemental material with pubertal assessment, IGF-1 and parental heights were provided.

No, the proposed treatment is not medically necessary.

The provider was offered the opportunity to provide the requested clinical information. Treating with GH without a valid diagnosis is not medically appropriate. Information is missing to validate ISS. The clonidine GH stimulation test was adequate to rule out GHD. In addition, supplemental material stated that a diagnosis of SGA was insufficient since there was catch-up growth by three years of age.

A diagnosis of ISS could not be substantiated by the data provided.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld. 

The patient is a female with history of hypertension, hyperlipidemia, diabetes, coronary artery disease, and a cerebrovascular accident (CVA) who presented with chest pain and generalized body pain. The patient was hospitalized. Vital signs were essentially normal. The oxygen saturation was normal. The patient was in no acute distress. The electrocardiogram (ECG) was not acute. The patient had a left ventricular ejection fraction (LVEF) of 60%. Troponins were negative. The patient remained stable. The patient underwent uncomplicated cardiac catheterization that demonstrated mild coronary artery disease (CAD). The patient was discharged. 

The inpatient hospital admission is not medically necessary. This patient presented with chest pain and remained stable. There was no congestive heart failure (CHF), respiratory distress, or ongoing symptoms suggestive of treatment refractory angina or angina equivalent. There was no severe arrhythmia, hemodynamic instability, or other serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection. There was not a need for prolonged intravenous (IV) medications, oxygen support, or introduction of high risk medications requiring ongoing in-hospital monitoring. There was not a severe catheterization related complication (i.e. severe bleeding, cerebrovascular accident (CVA)), need for invasive hemodynamic monitoring, or need for vasopressor or mechanical cardiac support. The patient has no evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG. In the setting of this case, an acute inpatient level hospitalization is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female with a past medical history of hypertension, hyperlipidemia, diabetes, obesity, and tobacco use who presented to the emergency department for evaluation of chest pain.  On arrival at the emergency department, the patient was afebrile, blood pressure was 124/81, respiratory rate was 18, heart rate was 61 beats per minute, and oxygen saturation was 98% on room air.  Twelve-lead electrocardiogram (EKG) demonstrated normal sinus rhythm without acute ST changes.  Initial labs were notable for a white blood cell (WBC) count of 10.6, troponin of zero, and D-dimer of less than 0.27.  Chest x-ray showed a compression plate with six cortical screws, and one old healed fracture of the right clavicle, but no acute findings were noted.  The patient was given aspirin and was admitted to the inpatient unit for further care.  She was evaluated by cardiology and underwent cardiac catheterization which demonstrated nonobstructive coronary artery disease.  Her ejection fraction was 55%.  Aggressive medical therapy for coronary artery disease was recommended and the patient was ultimately discharged with outpatient follow-up.

The inpatient hospital admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes, and no end organ malperfusion.  Although the patient had chest pain, she ruled out acute coronary syndrome with serial troponins.  Furthermore, there was no evidence of unstable angina given that the patient did not have any ischemic electrocardiogram (EKG) changes.  Additionally, the patient's coronary angiogram did not demonstrate any evidence of obstructive coronary artery disease.  The patient also did not have evidence of heart failure or symptomatic arrhythmias.  Consequently, based on the provided documentation, there is insufficient clinical data to support the medical necessity for an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure Activity
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient stay.

 The health plan's determination is overturned. 

The patient is a male who was brought to the emergency department after a witnessed seizure on the street. Pertinent history includes a brain aneurysm. Initial vital signs revealed a temperature of 98, heart rate (HR) 98, blood pressure (BP) 160/81, respiratory rate (RR) 16, peripheral capillary oxygen saturation (SpO2) 98% (percent) on room air. The initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell (WBC) 5.0, Hemoglobin (Hgb) 14.5, platelets (Plt) 144, blood urea nitrogen (BUN) 14, Creatinine 0.9, sodium (Na) 141, potassium 4.3, carbon dioxide (CO2) 28, Glucose 95, Calcium 8.2 and Mg 2.0. An electrocardiogram (EKG) did not reveal acute ischemic changes or significant abnormalities. A computed tomography (CT) head did not reveal acute pathology, but did note left frontal encephalomalacia. The patient was admitted to the hospital with an impression of new onset seizure. 

Inpatient hospital services were medically necessary for this patient.
The American Academy of Family Physicians (AAFP) published guidelines regarding the evaluation and management of seizure, mainly the first known episode. They note that the patient history and physical examination should focus on events directly preceding the seizure, the number of seizures in the past 24 hours, the length and description of the seizure, focal aspects (e.g., unilateral movements, eye deviation, head turning to one side), length of the postictal period, and the neurologic examination. This allows proper categorization as well as etiology identification and recurrence risk. Thereafter, in agreement with the American College of Emergency Physicians (ACEP), a Computed tomography (CT) of the head with and without contrast should be performed to look for structural lesions. Both the AAFP as well as the ACEP note that stable patients who have returned to baseline neurologic status in the emergency department may be discharged and scheduled for outpatient neurology if follow-up can be ensured. Additionally, laboratory tests can be performed but should be tailored to the individual patient and driven primarily by findings from the history and examination (eg. glucose level in a diabetic, liver function tests/ammonia in a cirrhotic).

The patient was initiated on the anti-epileptic drug Keppra. Clinical indications for admission to inpatient care were met. The patient had a brain disorder (eg, cystic encephalomalacia/porencephaly in the left anteromedial frontal lobe) that required monitoring available only at inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post motor vehicle accident
Treatment: Inpatient rehabilitation
The insurer denied coverage for inpatient rehabilitation.
The denial is upheld.

This is a male patient with history of hypertension, respiratory failure, immunocompromised, and who recently underwent open reduction and internal fixation (ORIF) following a right hip fracture. Surgically, the patient also underwent right lung lesion excision. The basis of this review is whether an acute rehab (rehabilitation) is appropriate. 

The records indicate the patient is hemodynamically stable, afebrile, and there are reports of inappropriate touching and behaviors. He is at times agitated. There is wandering into other residents' rooms and he has been educated regarding proper behavior. He is showing no signs of infection.

Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing medication management, skin care, labs and vital signs monitoring, and daily therapy can be provided at a lesser level of care. 

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

The insurer's denial of coverage for inpatient rehabilitation is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Sided Numbness
Treatment: Cervical Spine Magnetic Resonance Imaging (MRI)
The health plan denied the requested MRI as not medically necessary. 
The health plan's determination is overturned.

The patient is a woman with left sided neck pain associated with left arm numbness and muscle tightness. An evaluation by magnetic resonance imaging (MRI) of the cervical spine is the subject of this review. Six weeks of conservative or non-operative treatment were not documented by the physician.
At issue is the medical necessity for the requested cervical spine magnetic resonance imaging (MRI).

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

The patient has cervical neck pain associated with persistent neurologic symptoms of numbness and muscle tightness or spasticity. The patient has submitted physical therapy records to demonstrate that she has not responded to this conservative treatment. The clinical record also demonstrates that the patient has also used analgesics several times per week without improvement in the symptoms. As such, the symptoms are now chronic and not responsive to conservative therapies. Evaluation by an MRI was appropriate, as ordered by the patient's neurologist.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines
Treatment: Ubrelvy 50MG (milligrams) Tablet
The insurer denied Ubrelvy 50MG Tablet.
The denial is overturned.

The patient is an adult female. She experiences migraines on average once per week. She is currently on Pamelor (with a plan to wean off) for preventative therapy, and Ubrelvy for abortive therapy (via samples). She also tried triptans including Rizatriptan and had side effects. It is not documented how effective Ubrelvy has been for the patient. A previous trial with Nurtec was ineffective.

The patient's provider wishes to continue Ubrelvy. The request for Ubrelvy was denied coverage by the health plan, as it was not documented that patient had tried other medications including at least two different triptans. The denial is being appealed.

The requested Ubrelvy is medically necessary.

Continuation of Ubrelvy is medically necessary. It was documented in the chart that the patient had intolerance to Rizatriptan. According to the American Headache Society anti-CGRP (calcitonin gene-related peptide) guidelines, one is a candidate for anti-CGRP medications when one has tried and failed at least two different triptans, or is intolerant to one triptan. The patient having had side effects on Rizatriptan makes her a candidate for Ubrelvy when applying the American Headache Society anti-CGRP guidelines.

Therefore given the above, the requested Ubrelvy is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Irritable bowel syndrome. 
Treatment: Chlordiazepoxide-Clidinium. 

The insurer denied the Chlordiazepoxide-Clidinium. 
The denial is upheld. 

The patient is a male with irritable bowel syndrome (IBS). His medical doctor (MD) is requesting treatment with chlordiazepoxide-clidinium. 

No, the health plan should not cover the proposed treatment. 

While Chlordiazepoxide-clidinium is clinically appropriate and accepted standard of care for the treatment of irritable bowel syndrome (IBS), as there is no medical literature to support that it is more effective or safer than the preferred formulary alternatives dicyclomine or hyoscyamine, it should not be covered by the health plan. There is no documentation that the patient has failed the preferred dicyclomine or hyoscyamine, and no evidence that the patient would suffer adverse effects from dicyclomine or hyoscyamine, or that Chlordiazepoxide-Clidinium is more effective than dicyclomine or hyoscyamine to treat irritable bowel syndrome.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Comprehensive orthodontic treatment of the adolescent dentition and visits
The insurer denied: Comprehensive orthodontic treatment of the adolescent dentition and visits
The denial is overturned

The patient is a female who presented with a skeletal Class I malocclusion and crowding. She has an anterior open bite. She is treatment planned for orthodontics with extraction of teeth 5, 12, 21, and 28 to address the crowding and open bite, but the treatment was denied due to lack of medical necessity. The subject under review is the medical necessity for comprehensive orthodontic treatment of the adolescent dentition and visits.

Comprehensive orthodontic treatment of the adolescent dentition and visits are medically necessary for this patient. Anterior open bite patients are among the most difficult patients to treat.[1] One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.[2] Orthodontics combined with either orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite.[3] Orthodontic treatment is medically necessary for this patient due to the side effect described above, and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health/Attention deficit hyperactivity disorder (ADHD). 
Treatment: Pharmacy/Prescription Drugs.
The insurer denied JORNAY PM CAP 20 MG ER.
The denial is upheld. 

This is the case of a male with attention deficit hyperactivity disorder (ADHD). The physician-completed form indicates that the patient has tried Adderall extended release (XR) and Vyvanse with poor result due to long time to onset and missed doses. Jornay post meridiem (PM) was trialed at bedtime and worked better for the family with respect to compliance. The medication was denied by the health plan, as non-formulary medication and not all formulary medications have been tried and ineffective. Additional health plan medications include dexmethylphenidate extended release (ER), methylphenidate ER, and dextroamphetamine ER.
Records indicate a diagnosis of attention deficit hyperactivity disorder (ADHD) combined type.  The patient was initially doing well on Adderall XR 5 milligrams (MG), but did not tolerate the increase to 10 MG so he was switched to Vyvanse 10 MG.  Again, he did well on Vyvanse 10 MG for several years until recently.  He was switched to Jornay PM due to nighttime administration ease.
At issue is the medical necessity of Jornay PM capsule (CAP) 20 milligrams (MG) ER.

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

The requested health service/treatment of Jornay PM CAP 20 MG ER is not medically necessary for this patient.
The requested medication Jornay PM cap 20 MG ER is not medically necessary. This patient with ADHD has not done well on Adderall or Vyvanse due to timing difficulties and missed doses with morning administration. Jornay was recommended due to dosing convenience for the patient. There are formulary medications including methylphenidate ER, dexmethylphenidate ER, and dextroamphetamine ER which have not been tried and would be equally effective for this patient. Jornay was tried due to its evening administration; the active ingredient is methylphenidate.
Therefore, the requested health service/treatment of Jornay PM CAP 20 MG ER is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: Low back pain

Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and
64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (Intracept)

The insurer denied coverage for Intracept procedure.

The denial is upheld.

This adult has chronic low back pain. The patient has had medication trials including Celebrex, Tylenol, Lyrica, Gabapentin and Tramadol. The patient has had epidural steroid injections, trigger point injections and physical therapy as well as a home exercise program. Magnetic resonance imaging (MRI) shows Modic changes at L4, L5 and S1 (lumbar 4, lumbar 5 and sacral 1). The request is for radiofrequency ablation (RFA) of the basivertebral nerves at L4, L5 and S1.

In 2018, Fischgrund and colleagues (1) published a double-blind, sham-controlled randomized controlled trial (RCT) evaluating the Intracept system and RFA of the basivertebral nerve for the treatment of chronic low back pain. The primary efficacy endpoint was the comparative change in Owestry disability index (ODI) from baseline to 3 months. 

Additional data from the intervention group have been published; 24-month data in 2019 and five-year data in 2020. Data beyond 12 months on pain and function outcomes in the sham-treated group were not available as unblinding occurred at that time and most individuals crossed over to treatment with the Intracept system. Thus, long-term comparative outcomes are not known.

A second RCT evaluating the Intracept system, known as the INTRACEPT trial (2), was published by Khalil and colleagues in 2019. The trial was open label and compared intraosseous RFA treatment to standard care in individuals with at least 6 months of chronic low back pain who had not responded to at least 6 months of conservative care. 

In sum, the publications to date have been company sponsored and had methodology flaws. There are no published data on long term complication rates. There are other evidence- based interventions available to this patient. 

The procedures are unlikely to be more beneficial than the standard approaches.

The carrier's denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and
64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (Intracept) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Humerus Fracture

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is an adult with a history of obesity. The patient presented to the emergency room (ER) with complaints of left leg pain after falling. Imaging revealed a left mid shaft humerus fracture. The patient was admitted for care. The patient underwent an open reduction internal fixation (ORIF) of the left mid shaft humerus fracture. The patient tolerated the procedure well. The patient was evaluated by physical therapy and occupational therapy (PT and OT) after surgery. The patient was discharged.

The records show the patient sustained an isolated closed fracture to her humerus. This was a low energy type of injury. There were no other body parts affected. The initial management was application of a splint. She was then scheduled for surgery the next day.

Her pain was controlled. There was no urgency reported to perform the surgery. The facts were the operation was completed two days later. Her post-surgical course was non-complicated.

She did not require treatment for an underlying medical condition.

The patient's operation was completed. There were no reported problems. She was able to tolerate oral pain medication. Her vital signs were stable. There was no evidence of bleeding nor wound issues. She was independent and able to be mobilized. These findings do not substantiate an indication for acute admission. The services provided after her surgery could have been obtained at a lower level of care.

There were no extenuating circumstances to substantiate the admission.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Lung Infection; Hypoxia, Pneumonia.
Treatment: Inpatient Admission.
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who was admitted to the hospital for pneumonia. She has no significant medical history. On presentation, she had 1 week of coughing and dyspnea. She had a chest x-ray and was found to have right lower lobe pneumonia. She was COVID-negative. The patient was started on intravenous (IV) antibiotics. She transiently had diarrhea, but this resolved. Her white blood cell count (WBC) was 11.1. The patient was given intravenous fluids during the admission. It does not appear there was any hypoxia or fever during the admission. Her condition improved and she was stable at discharge.
The question at hand is whether the patient met the medical necessity for the acute inpatient level of care.

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

The patient in question did not meet the medical necessity for the acute inpatient level of care per current literature or standard of care. According to Mandell et al., (2007), File (2003), and Musher et al., (2014), the patient did have uncomplicated community-acquired pneumonia. There were no severe features or extenuating circumstances which would have required the acute inpatient level of care. There was no persisting hypoxia, fever, or other symptoms. Her condition improved the following day, and she was discharged. Observation would have been appropriate in this case.