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

Diagnosis: uterine fibroid embolization

Treatment: inpatient stay

The insurer is denied coverage for inpatient stay.

The denial is overturned. 

This female patient has a history of anemia, human papilloma virus infection, hypertension, pneumonia, sexual dysfunction, uterine leiomyoma, menorrhagia.

This case involves a female who presented to the emergency department. The submitted documentation indicated per history and physical she presented with symptomatic uterine fibroids. The documentation indicated on physical exam her blood pressure was 122/82 with a pulse of 80 beats per minute and respirations 18. Oxygen saturation was 92%. The laboratory studies previously referenced were showing hemoglobin at 8.0. The documentation detailed she was recommended to undergo uterine fibroid embolization. She was admitted and did undergo embolization. She continued with observation. The documentation indicated postoperatively there was no bleeding or swelling at the procedure site. It was recommended she continue treatment and be discharged following day. The documentation detailed there was no documented adverse events and therefore, she was discharged the following day with instruction to follow-up.

The inpatient stay was medically necessary for the patient to be observed following uterine artery embolization. These patients should be observed for development of acute arterial access complications and management of postoperative pain, which usually requires intravenous (IV) pain medications and patient-controlled analgesia.

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

The carrier's denial of coverage for inpatient stay is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Surgical Services. 
The insurer denied leg revascularization. 
The denial is overturned.

The patient is a male with multiple medical problems including, hypertension, hyperlipidemia, diabetes, chronic kidney disease, and history of smoking who was evaluated by the vascular surgeon for bilateral leg pain that was worse with ambulation. The patient was noted to have palpable femoral artery pulses bilaterally and non-palpable distal pulses bilaterally. Lower extremity arterial studies performed demonstrated bilateral peripheral arterial disease. The patient underwent bilateral lower extremity angiogram which demonstrated bilateral distal superficial femoral artery disease and proximal tibial artery occlusions.
The patient was seen in follow up where the results of the angiogram and treatment options were discussed including bypass surgery. The patient wanted to proceed with bypass surgery of the right leg. Vein mapping performed demonstrated patent right great saphenous vein and patent right small saphenous vein. The patient was seen in follow up, for discussion regarding his right leg bypass surgery by the surgeon. The patient's questions were answered. The surgeon will schedule his surgery. The issue at hand is whether or not the procedure, right lower extremity revascularization, is medically necessary.

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

The requested service of leg revascularization is medically necessary for this patient. The patient has symptomatic peripheral arterial disease. Lower extremity arterial studies performed demonstrated bilateral peripheral arterial disease. The patient underwent bilateral lower extremity angiogram demonstrated bilateral distal superficial femoral artery disease and proximal tibial artery occlusions. Treatment for this patient is medically necessary. Revascularization of the right lower extremity in this patient with right lower extremity arterial disease is medically necessary and is the standard of care in patients with symptomatic lower extremity arterial disease. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied an increase in Consumer Directed Personal Assistance Services. 
The denial is upheld in whole. 

The patient is a female with a past medical history significant for Alzheimer's disease, congestive heart failure, hypertension, weight loss, urinary incontinence and fecal incontinence, and a sacral decubitus ulcer stage I. The patient is currently receiving personal care services, Consumer Directed Personal Assistance Services (CDPAS) 12 hours per day times ()7 days a week for a total of 84 hours a week.  The patient is now requesting an increase in Consumer Directed Personal Assistance Services to 24 hours x 7 days a week live-in, for a total of 91 hours per week.
At issue is the medical necessity of an increase in Consumer Directed Personal Assistance Services to 24 hours x 7 days a week Live-in, for a total of 91 hours per week.

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

The requested health service of an increase in Consumer Directed Personal Assistance Services to 24 hours x 7 days a week Live-in, for a total of 91 hours per week is not medically necessary for this patient.
The patient has advanced Alzheimer's disease and would be considered total care including activities of daily living (ADL) s and Instrumental activities of daily living (IADL) s. There is a noted functional decline, and the patient is incontinent of urine and bowels. She is requesting live-in services through her power of attorney, currently she has services 12 hours a day  7 days a week for total of 84 hours a week. She is requesting an additional 1 hour a day for a total of 91 hours a week. Uniform Assessment System (UAS) State of New York dated 6/2/2021, was noted that the patient has extensive care needs. The patient is currently on hospice and does receive hospice services with an aide, 1-1/2 hours a day twice a week and currently resides with her caregiver.
Services provided can be performed in the allotted time. Additional services for monitoring and companion care without additional need for IADLs/ADLs would not be considered medically necessary. The patient's functional status at her last evaluation was total care. It does not appear that her care has progressed to more when comparing the previous evaluation with her current status. There are no needs noted by the caregiver that could not be provided during the 12 hours of service.
Therefore, the increase in Consumer Directed Personal Assistance Services to 24 hours x 7 days a week Live-in, for a total of 91 hours per week  is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent.
The insurer denied Dupixent. 
The health plan's determination is upheld.

The patient is a  female with severe atopic dermatitis to the trunk and extremities, treated with multiple topical steroids (triamcinolone, hydrocortisone, mometasone, clobetasol, halobetasol, fluticasone, betamethasone), Tacrolimus and oral antibiotics. The provider is requesting Dupixent. This is the subject of this review.

Dupixent is not medically necessary for this patient.
This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. There is no documentation of a trial and failure to phototherapy, as well as systemic immunosuppressants such as cyclosporine, which are used in severe atopic dermatitis for this age group. While Dupixent has been approved to age 6 and is under investigation for children as young as 6 months. In this case, the patient has not tried and failed all other appropriate therapies for atopic dermatitis.
Therefore, Dupixent is not appropriate or medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-Small Cell Lung Cancer
Treatment: Proton beam Therapy
The insurer denied proton beam therapy. The health plan's determination is upheld. 

This is the case of a male who presented with an abnormal x ray chest. This was followed by a computed tomography (CT) chest and positron emission tomography (PET) followed by biopsy. He was started with chemo-immunotherapy. He is being evaluated for radiation therapy (RT) using Proton beam therapy. This is the subject of review.

The requested Radiation Therapy (Proton Beam Therapy) is not medically necessary for this patient.

Medically necessary treatment is defined as treatment which is in accordance with generally accepted standards of medical practice in the United States The generally accepted standards of medical practice in the United States for lung cancer is intensity modulated radiation therapy (IMRT). Proton beam is being evaluated under NCI (National Cancer Institute) sponsored trials.

Proton beam has been used to treat several cancers including lung cancer in last several years. Most published reports are retrospective studies with small number of patients or single institution phase II studies. There is no published report on the long term outcome of proton beam therapy for lung cancer from randomized controlled trial or cohort trials in peer reviewed published literature. There are several phase II trials going on evaluating responses and toxicities of proton therapy for lung cancer. The outcome of these phase II trial may lead to phase III trial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied Proton Beam Therapy for medical necessity. 
The denial is upheld in whole. 

This patient is a female with a left breast invasive ductal carcinoma with clinical stage T2N1M0 (TNM Staging System). She received neoadjuvant chemotherapy with complete response on pathology after lumpectomy and axillary nodal sampling. Radiation therapy has been recommended to the left breast and nodal regions to decrease her risk of recurrence and proton beam approach is requested.

At issue is the medical necessity of Proton Beam Therapy.

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

The requested health service/treatment of Proton Beam Therapy is not medically necessary for this patient.

Proton beam radiation therapy is not considered a standard approach of treatment for external beam breast irradiation for invasive ductal carcinoma. There are not adequate clinical trials published in peer reviewed medical literature supporting its use as equivalent, or better or safer than standard photon radiation therapy such as three dimensional (3D) conformal or intensity modulated radiation therapy (IMRT). There are studies ongoing looking at the efficacy and safety of the proton beam approach. There are very few small studies published that are reported to show improved normal heart and lung volumes exposed to radiation. More studies with larger numbers of patients are needed to be evaluated and published in peer reviewed journals to determine the efficacy and safety of this approach of postoperative radiation therapy for breast carcinoma patients. Until these studies are completed the requested proton beam radiation therapy for this patient and her clinical scenario is not medically necessary.

Therefore, the requested health service/treatment of Proton Beam Therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol use disorder

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is overturned. 

This male patient has a history of diabetes, alcohol use disorder and prior alcohol withdrawal episodes.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR)  he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily including 1.5 pints of vodka per day, and he required and received multiple IV (intravenous) detoxification medications for withdrawal management including IV Diazepam 3 times and IV Ativan which reportedly was given and these were to  modify withdrawal from alcohol and prevent more complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for this. This was a high risk patient in active withdrawal with significant withdrawal symptoms who required multiple IV detoxification medications. He did require 24 hour medical hospital treatment for alcohol detoxification and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. He required at least the entire days from as he was at risk for life threatening and complicated withdrawal including delirium tremens.

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

The carrier's denial of coverage for inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: attention deficit hyperactivity disorder (ADHD)

Treatment: Adderall extended release

The insurer is denied coverage for Adderall extended release

The denial is overturned. 

This female patient has a history of generalized anxiety disorder, attention deficit hyperactivity disorder and anemia.

Adderall is the brand name and amphetamine/dextroamphetamine is the generic equivalent. Both are USA Food and Drug Administration (FDA) approved medications, and it was reported that she had a diagnosis of ADHD, and this is a diagnosis that is diagnosed in adults now as well as children. Adderall XR is long-acting Adderall or generic equivalent amphetamine/dextroamphetamine XR (extended release). The FDA maximum recommended dosage for Adderall XR for treating ADHD is 40 milligram (mg) per day so the request for 5 mg per day is considered within the FDA approved recommended dosing. As a result, the recommendation is to reverse the previous decision and approve coverage for Adderall XR 5 mg per day or its generic equivalent, which is amphetamine/dextroamphetamine XR 5 mg per day.

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

The carrier's denial of coverage for Adderall extended release is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure (22899 and C9752)
The insurer denied the Intracept Procedure (22899 and C9752).
The denial is upheld.

The patient is a male with a history of chronic low back pain. His pain has not
responded to epidural steroid injections, medial branch blocks, radiofrequency
ablation (RFA), physical therapy (PT), acupuncture and pain medication. He has
done physical therapy and has seen a chiropractor. He has tried various
medications. Physical exam shows decreased range of motion (ROM).

No, the proposed Intracept procedure is not medically necessary.
The requested Intracept procedure is not medically necessary. The requested
health service or procedure is not likely to be more beneficial than standard
treatments.

The patient is a male with a history of chronic low back pain. His pain has not
responded to epidural steroid injections, medial branch blocks, radiofrequency
ablation, physical therapy, acupuncture and pain medication. He has done physical
therapy and has seen a chiropractor.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an
intradiscal procedure. It is a new Food and Drug Administration (FDA) approved
intraosseous nerve ablation for the treatment of chronic low back pain in the
treatment of vertebrogenic related chronic low back pain. It is typically used in
patients with significant Modic type I or type II vertebral endplate changes, typically
in situations where conventional and typical options have been exhausted.
Alternatives, such as spinal fusion, do not have good long-term results in the
literature for axial low back pain without instability. Spinal fusion is a very invasive
procedure with high morbidity and poor outcomes, compared to the Intracept
procedure. In fact most recent articles show less than 50 percent improvement for
the treatment of chronic low back pain with spinal fusion.

However, the patient has not failed sacroiliac (SI) joint interventions which is
common cause of axial low back pain. In situations where all non-invasive options
have failed, epidural steroid injections could also be considered, although typically
used in patients with radicular symptoms. Spinal cord stimulation is also an
alternative, however has not been shown to have excellent results in primarily axial
mechanical/discogenic type pain. Chronic opiates are not without risk, and can
lead to addiction and overdose. Therefore, while the Intracept procedure is a
reasonable option, it should be employed after all conventional and evidence
proven alternatives have failed. In addition, based on the magnetic resonance
image (MRI) report and images available, no endplate changes or Modic changes
are noted. Given the above, the requested Intracept procedure is not medically
necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Migraine
Treatment: Formulary exception for Botox 200 Unit INJ, Pre-service
The insurer denied the Formulary exception for Botox 200 Unit INJ, Pre-service.
The denial is upheld.

The patient is a female with chronic migraine headache disorder.  She has tried and failed or could not tolerate topiramate, propranolol and amitriptyline. The provider has requested Botox for migraine prevention. This was denied coverage by the health plan, as she has not tried and failed three oral migraine preventive agents from two different therapeutic classes for at least 60 days duration.

No, the health plan should not cover the formulary exception for Botox.
The medical records do not support that the listed oral migraine preventive agents were tried for at least 60 days. There is no documented reason as to why the patient cannot be treated with oral migraine preventive agents at therapeutic doses for at least 60 days.  These medications are first-line, standard of care treatments to prevent migraine (Schwedt). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Botox relative to the preferred oral agents (Frampton and Silberstein).
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abscess.
Treatment: D2750 Crown - Porcelain Fused to High Noble Metal, Tooth #8 and D3310 Endodontic Therapy Anterior Tooth (excluding final restoration), Tooth #8.
The insurer denied the D2750 Crown - Porcelain Fused to High Noble Metal, Tooth #8 and D3310 Endodontic Therapy Anterior Tooth (excluding final restoration), Tooth #8.
The denial is overturned, in part.

The patient is a female.  Tooth #8 has a two-surface (mesio-lingual) composite restoration present. The tooth also has a periapical radiolucency (abscess) at the end of the root.

Yes, in part; the root canal treatment, code D3310, was medically necessary.  However, the crown, code D2750, was not medically necessary.
The tooth had an infection (abscess) that required a root canal procedure to correct the problem. 

Since there was no new decay in the tooth that required any drilling out of the existing conservative filling, there was still sufficient tooth structure present after the root canal procedure was done. Therefore, in this case, a crown was not necessary to restore the tooth. The patient stated that the tooth became darker, but that is an aesthetic issue, not a functional one.  The crown is not medically necessary.

Yes, in part;  the health plan acted reasonably, with sound medical judgment and in the best interest of the patient in denying the crown; however, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in denying the root canal as it was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Liver Cirrhosis. 
Treatment: Continued Inpatient Hospital Admission. 

The insurer denied the Continued Inpatient Hospital Admission. 
The denial is upheld. 

This is a male has a history of decompensated non-alcoholic cryptogenic liver cirrhosis complicated by recurring ascites requiring large volume paracentesis, esophageal bleeding status post banding, jejunal arteriovenous malformation (AVM) status post ablation, hepatic encephalopathy requiring intubation, chronic hypoxic respiratory failure, COVID-19, deep venous thrombosis (DVT) status post inferior vena cava (IVC)  filter, iron deficiency anemia requiring frequent transfusions, acute kidney injury, arthritis, thrombocytopenia, hypertension, recurrent gastrointestinal (GI) bleed, cellulitis with abscess requiring surgical drainage, nonhealing sacral wound, Clostridium difficile, and severe protein calorie malnutrition. 

The patient was admitted from a subacute rehabilitation to inpatient level of care for TIPS (transjugular intrahepatic portosystemic shunt) procedure and evaluation for a liver transplant. 

Per progress note, it is stated: Dispo - suspect he will continue to require intermittent transfusion so LTACH (long-term acute care hospital) or another facility may be best option though the latter would only accept him in a palliative setting. 

For the dates of service in question, he continued to work with physical therapy and occupational therapy and his labs were closely monitored.  The plan was for LTACH (long-term acute care hospital).  The patient was stated to be stable. 

The patient had chronic issues and intermittent anemia / thrombocytopenia requiring periodic blood transfusions.  All of this could have been accomplished at a lower level of care such as LTACH (long-term acute care hospital). 

An in-patient level of care was not necessary beyond the initial inpatient stay, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, did not have an elevated white count, did not have acute liver failure, did not have active or ongoing gastrointestinal bleeding, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left index finger cellulitis. 
Treatment: Full hospital admission. 

The insurer is denied coverage for full hospital admission. 

The denial is overturned. 

This female patient has a history of scleroderma, gastroesophageal reflux disease (GERD), Raynaud's, and interstitial lung disease (ILD). 

The patient was started empirically on intravenous antibiotics (vancomycin and ceftriaxone) for a left index finger cellulitis. X-ray of the hand did not show any soft tissue abnormalities or any osseous erosive changes. Infectious Diseases consulted and recommended magnetic resonance imaging (MRI) of the hand which she could not tolerate due to underlying anxiety. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics (Augmentin and minocycline) as an outpatient. 

According to documentation, patient was admitted with a left index finger infection. She was afebrile but tachycardic (heart rate-103). Laboratory results were notable for leukocytosis (WBC-17.3). Based on above findings in a high-risk patient immunocompromised with documented failure of two courses of outpatient antibiotics, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation. 

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

The carrier's denial of coverage for full hospital admission is overturned.  The medical necessity is substantiated.