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

Diagnosis: Fever - Mononucleosis
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is upheld

This is a patient with a history of asthma presented to the emergency department with complaints of fever, sore throat, and odynophagia.

Vitals on presentation included: T (temperature) 101 F (farenheit), BP (blood pressure) 97/65, P (pulse) 96, RR (respiratory rate) 20, O2 sat (oxygen saturation) -100% on RA (room air). Laboratory results included the following: WBC (white blood cell count) 6.3, HGB (hemoglobin) 13.9, HCT (hematocrit) 36.7, creatinine-0.8, glucose 87, AST (aspartate aminotransferase) 138, ALT (alanine transaminase) 225, alkaline phosphate 265, viral respiratory panel was negative; the heterophile AB (antibody) test was positive, and CRP (c-reactive protein) 6.8.

The patient was admitted to the hospital for fever and a sore throat. An ultrasound of the neck revealed no abscess but showed a cluster of enlarged lymph nodes. Laboratory results were notable for positive heterophile antibody. He was treated with intravenous fluids and pain medications. The patient continued to experience difficulty tolerating oral intake. Infectious Disease was consulted and recommended a dose of dexamethasone. All other diagnostic tests were negative. The patient remained afebrile, and hemodynamically stable. He was discharged to continue outpatient management.

According to documentation, the patient presented with mononucleosis-type symptoms. He had a low-grade fever, otherwise, he was hemodynamically stable with a normal WBC. The patient had no evidence of pneumonia or a systemic infection. Ultrasound of neck showed lymph node swelling but no abscess. Mononucleosis is a self-limiting infection, based on patient's poor oral intake, observation level of management was indicated. The patient did not meet criteria for acute hospitalization.  

Prior determination of the denial of the hospital admission is upheld.

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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypothyroidism, Parkinson disease. 
Treatment: Increase Home Care / Personal Care Level 2 Personal Care Service Per 15 minutes Increase from 40  to 70 Hour(s) per week. 

The insurer denied the Increase Home Care / Personal Care Level 2 Personal Care Service Per 15 minutes Increase from 40  to 70 Hour(s) per week. 
The denial is overturned. 

The patient is a male. He is reported to have multiple comorbidities including diabetes, hypothyroidism, and Parkinson disease. He has been having multiple falls and needs help and supervision with all his ADLs (activities of daily living). The patient has dizziness and has progressive neurologic disease. 

The review for increased personal care services from 40 hours/week to 70 hours/week. The health plan's reason for prior denial of coverage was that they contend that services are not medically necessary and are custodial in nature. 

Yes, the requested Increase Home Care / Personal Care Level 2 Personal Care Service Per 15 minutes Increase from 40 to 70 Hours per week is medically necessary. 
The patient has multiple comorbidities, including diabetes, Parkinson disease, hypothyroidism and rheumatoid arthritis. The patient has been experiencing significant cognitive and functional decline. The patient is unable to perform any activities of daily living without any help. The patient needs help with eating, dressing, toileting. The patient has been experiencing multiple falls. The patient is at increased risk of falls because of underlying diagnosis of Parkinson's disease. The patient is at high risk of worsening clinical condition, falls and major bleeding. The requested services are medically necessary and appropriate. The plan approved 40 hours/week are not enough, since the patient needs help with all ADLs (activities of daily living) and to prevent falls. He has frequent urinary incontinence as well. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 
The patient has progressive neurologic disease and has unsteady gait. The patient has urinary incontinence as well. The patient needs increase in home care services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shoulder Pain. 
Treatment: Shoulder Procedure (29827, 29826). 

The insurer denied the Shoulder Procedure (29827, 29826). 
The denial is overturned. 

This patient is a female with shoulder pain. She had sustained a fall on the ice. She reported ongoing pains despite conservative treatments of physical therapy (PT) and injection. 

The patient's physical examination was significant for positive Hawkins, positive Neer, limited motion and weakness.  The magnetic resonance image (MRI) report was significant for: partial tear and pathology.  The physician performed arthroscopic surgery (29826 and 29827). 

Yes, the proposed shoulder procedure (29827, 29826) was medically necessary. 
The documentation was consistent to substantiate necessity of surgery. There was evidence of a traumatic event. There were continued subjective complaints with correlative physical findings. The imaging studies showed pathology. A differential diagnosis and pain generator had been defined. A full course of conservative treatment had been provided without benefit (physical therapy, medication and injection). The next step would be surgery. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

All information was not taken into account by the health plan. Documentation was provided of symptoms for over one year. There was a full course of conservative treatment provided. Surgery would thus be indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision - Thyroid eye disease.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Rituxan.
The denial is overturned. 

The patient is a female with thyroid eye disease for whom Rituxan has been recommended. Rituxan was previously denied as the patient did not have one of the diagnoses considered medically necessary. Upon appeal, it was identified that the patient completed a course of Tepezza without improvement and experienced side effects including tinnitus, loss of smell, and odynophagia. The provider stated that the literature supports a role for rituximab in these patients. A note confirmed the patient having received Tepezza with side effects including ear fullness, anosmia, and weight gain. The patient has no history of a tuberculosis (TB) diagnosis.
At issue is the medical necessity of Rituxan.

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

Yes, the requested health service/treatment of Rituxan is medically necessary for this patient.
According to Bartelena et al, second-line treatments for moderate-to-severe and active Graves Orbitopathy (GO) include (a) the second course of intravenous (IV) methylprednisolone (7.5 gram [g]) subsequent to careful ophthalmic and biochemical evaluation, (b) oral prednisone/prednisolone combined with either cyclosporine or azathioprine; (c) orbital radiotherapy combined with oral or IV glucocorticoids, (d) teprotumumab; (e) rituximab and (f) tocilizumab.
Ostrowski et al identified 43 cases of thyroid eye disease treated with rituximab (Rituxan) in the medical literature and suggest that rituximab may represent an attractive new treatment option for thyroid eye disease, especially in the case of disease that is refractory to current treatment strategies.
In a trial by Salvi et al, rituximab either as two 1 g infusions or one 500 milligrams (mg) infusion was compared with intravenous methylprednisolone (IVMP). At 52 weeks, rituximab was superior, with no reactivation of thyroid eye disease (TED) in the rituximab treatment arm, as compared with 31 percent (%) reactivation rate in the IVMP group. Secondary endpoint results were mixed, with no significant reduction of mean proptosis and Gorman diplopia score in both treatment arms, although the rituximab group showed greater motility and improvement in quality-of-life scores at 52 weeks.
In this case, the patient had already tried and failed teprotumumab. A review of the peer reviewed medical literature identifies support for the safety and efficacy of rituximab for this patient's condition. Therefore, the requested Rituxan would be established as medically necessary per standard of care.
Therefore, the requested health service/treatment of Rituxan is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders - Psoriasis
Treatment: Pharmacy/Prescription Drugs
The health plan denied Humira as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with psoriasis. The total body surface area affected is 15 percent (%). He has tried and failed Clobetasol and betamethasone. He has been recommended for Humira by his provider.
At issue is the medical necessity of the medication Humira.

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

According to the National Physician Specialty Society Recommendations for psoriasis, the American Academy of Dermatology Psoriasis Guidelines, and dermatology literature, methotrexate is an effective treatment for the management of psoriasis [1, 2]. Within the peer-reviewed literature, West et. al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% of patients achieve psoriasis area and severity index (PASI75) at the primary endpoint. Thus, methotrexate is an effective first-line treatment for the management of psoriasis [3].

Per the medical and scientific literature, evidence based clinical practice guidelines, and the information provided by the patient, the request for Humira is not medically necessary. It is noted that the patient has failed the topical steroid Clobetasol. However, the patient has no true contraindications listed to a preferred treatment modality that would make the use of Humira medically more appropriate than the other options.

Therefore, the administration of Humira is not strongly supported for this patient, and Humira is not medically necessary for this patient based on the current evidence-based medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite.
Treatment: comprehensive orthodontic treatment and visits.
The plan denied: comprehensive orthodontic treatment and visits.
The denial is: Upheld.

The patient is a male with a Class II subdivision right occlusion with moderate overjet and a deep overbite. The maxillary and mandibular have very moderate crowding. He is in the mixed dentition phase of dental development. He is treatment planned for orthodontic treatment with headgear to correct his malocclusion. The subject under review is the medical necessity for comprehensive orthodontic treatment and visits.

The health plan's determination is upheld

There is no medical reason to correct his malocclusion with braces. Comprehensive orthodontic treatment and visits are not medically necessary for this patient.
The patient has moderate crowding. His bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage) on this patient. The patient does have a deep bite, however, that alone is not a medical necessity to treat.
There are functional problems that can occur in dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1- This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a slightly excessive overjet, but this amount of overjet does not negatively affect oral health-related quality of life.2- If his teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. The requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: breast wound/dehiscence
Treatment: Inpatient stay
The insurer denied the inpatient stay.
 The health plan's determination is overturned. 

The patient is a female who initially presented to the emergency department with concerns for left breast pain and wound dehiscence. Pertinent history included breast augmentation about a week prior to presentation. Initial vital signs revealed a temperature of 102.9 degrees Fahrenheit , heart rate (HR) 143, blood pressure (BP) 100/62, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 97% (percent) on room air. Initial examination documented left breast erythema with bloody drainage. Initial laboratory testing revealed a white blood cell count (WBC) 12.7, Hemoglobin (HGB) 9.6, platelets (Plt) 458, Na (sodium) 136, K (potassium) 4.3, blood urea nitrogen (BUN) 6.0, Cr (creatinine) 0.6, Glucose 118, and Lactic acid 0.9. Urinalysis was unremarkable. A Chest radiograph was unremarkable. A computed tomography (CT) Chest revealed subcutaneous edema, but no drainable rim-enhancing abscess collection. The patient was placed in the hospital thereafter with an impression of sepsis secondary to left breast cellulitis in the setting of recent breast augmentation surgery. 

The inpatient hospital admission was medically necessary. In this particular situation, the patient presented with a left breast infection in the setting of recent breast augmentation despite five days of oral amoxicillin-clavulanic acid. Initial evaluation was concerning for clear signs of systemic sepsis. Broad spectrum parenteral antibiotics were initiated and multiple consultations were obtained. Infectious disease recommended empiric parenteral antibiotics well beyond the observation care time frame. In addition, despite several days of parenteral antibiotics, the left breast incision displayed progressive necrosis concerning for a full-blown implant infection. The patient left against medical advice prior to determination of surgical exploration / intervention.
Moreover, clinical indications for admission to inpatient care were met. The patient had failure of outpatient therapy, persistent tachycardia beyond the observation time frame, parenteral antibiotics required beyond observation care, and a potential surgical procedure not amenable to outpatient, emergency department, or observation care.
Appeal type: Medical necessity
Decision: Upheld

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

This adult male was hospitalized for chest pain. He presented to the hospital emergency department for detox and while in the unit developed chest pain. His past medical history is pertinent for alcohol abuse, delirium tremens (DTs), opioid abuse with methadone dependence, smoking, hypertension (HTN), prediabetes, gastroesophageal reflux disease (GERD) and hyperlipidemia (HLP). The patient's vital signs were stable. His electrocardiogram (EKG) showed sinus rhythm (SR) and Q-waves in V1 and V2. There were no arrhythmias or elevated troponin documented. Chest x-ray was negative. The clinical impression was alcoholic gastritis and alcohol withdrawal. Treatment included Ativan, which was slowly weaned. The claim was denied; this is an appeal that the requested acute inpatient hospital stay was medically necessary for this patient.

The proposed inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, acute myocardial infarction, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care the patient received, including uncomplicated alcoholic gastritis and alcohol withdrawal, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve treatment in spine 
The insurer denied nerve treatment in spine.
The determination is upheld.

This is a patient with a history of low back pain. He has had physical therapy, injections and medications without relief. He is a non-smoker. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows degenerative changes at L (lumbar) 3-4. The provider has recommended interosseous ablation of the basivertebral nerve (BVN) at L3-4 and this is under review for medical necessity.

The requested nerve treatment is not medically necessary. This is a patient with a history of low back pain. While the requested procedure is a promising technology, further non-industry research has been recommended. Urits, et al cite "chronic low back pain (CLBP) is a difficult yet common diagnosis that affects a significant portion of patients worldwide. In efforts to combat this debilitating disease, researchers have made great progress in understanding the pathophysiology of lower back pain (LBP) in addition to unveiling the anatomy of the vertebrae in search of appropriate treatment options. As a result, with the growing evidence supporting the vertebrogenic model that involves the BVN, radiofrequency (RF) ablation of the BVN has emerged as a possible minimally invasive procedure to treat LBP. Several studies have supported the safety, durability, and efficacy of RF ablation of the BVN. There is also convincing evidence that BVN ablation is more beneficial than the current standard of care for the treatment of CLBP. However, reproducible large randomized controlled trials (RCTs) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future".

Conger, et al cite "There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings".

Michalik, et al cite "BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the lumber (L) 3 to sacral (S) 1 verterbral endplates (VEPs) who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results".

Therefore, the requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer
Treatment: Inpatient hospital admission 
The insurer denied coverage for an inpatient hospital admission. 
The denial is upheld.

This is a male patient with a history of prostate cancer. The patient was seen in his urologist's office for a new patient evaluation. A bone scan was negative for any metastatic disease. The physician requests coverage for radical prostatectomy in an inpatient setting. The insurer has denied coverage for this as not medically necessary, stating that the records did not show why an inpatient hospital admission was required as there was no documentation of a severe underlying condition or medical comorbidity. 

The appeal by the urologist is noted and read in detail. Per MCG (Milliman Care Guidelines) Health (26th) prostatectomy, radical the goal LOS (length of stay) is Ambulatory or 1 day postoperative. The usual course is that patients are kept in the hospital overnight for observation to ensure a safe discharge, and their LOS is usually less than 24 hours. This patient had no serious underlying medical condition or co-morbidity that would have required an inpatient hospital admission.

The surgery to remove the prostate in an inpatient hospital setting is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for surgery to remove the prostate in an inpatient hospital setting is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot Pain and In-toeing.
Treatment:  Durable Medical Equipment (custom shoe inserts L3020 x 1).
The insurer denied the  Durable Medical Equipment (custom shoe inserts L3020 x 1).
The denial is overturned.

The patient is a male. The request is for custom shoe inserts. All enclosed documentation was reviewed. The appeal letter has no rationale to the request, except that it warrants the request.

Documentation states that the child was seen by his PCP (primary care provider).  According to the mom, the patient intones with his right foot.

Per the visit note, in the care plan, orthotics were strongly advised, and if that does not help, follow up with pediatric orthopedic.

Yes, the requested health service is medically necessary.
After careful review, it is noted that standard of care in children with in-toeing is to use an arch support as requested.  The goal of the orthotic (arch support) is to protect the foot from compensation and protect it from any long term complications that could occur.

The custom shoe inserts are medically necessary to prevent any future complication that could occur.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Although there is no guarantee to orthotic use, and the patient is not experiencing pain, and intoeing in young children does resolve on its own in some cases, to avoid any complications that may be unseen due to compensation, orthotics is standard of care in treatment to avoid such negative outcome.