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

Diagnosis: Left Tibial Plateau Fracture

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is the case of a female patient with a past medical history of neurofibromatosis and osteopenia who presented to the hospital with left leg pain, swelling and deformity after a fall. X-ray showed evidence of a left tibial plateau fracture. There was also question of possible medial subluxation of the femur. The plan was to admit the patient for pain control and further management by Orthopedics. The patient underwent Open Reduction and Internal Fixation (ORIF), left tibial plateau fracture. The patient tolerated the procedure and there were no complications. She was discharged. 

The records show the patient sustained a complex type of fracture. She underwent the procedure the day following admission. Her operation was extensive, requiring a 12-inch incision with open reduction and stabilization to fracture. Her postsurgical course was complicated by the need of catheterization (urinary retention). It would be important to assess her bladder emptying capacity as if this continued, she would require genitourinary (GU) consultation. She also was found to have no motor function below the block. It would be important to follow the status of her nerve to assess if additional treatments would be in order; for example, she had a foot drop after surgery. 

These findings do not substantiate an uncomplicated course and support the admission and length of stay. The health plan did not act reasonably or with sound medical judgment.

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

Diagnosis: Excessive Daytime Sleepiness

Treatment: Wakix 17.8 milligram (mg) tablet, quantity of 39 for 23 days

The insurer denied coverage for Wakix 17.8 milligram (mg) tablet, quantity of 39 for 23 days.

The denial is overturned.

This is a male with history of prior amphetamine abuse and excessive daytime sleepiness of unclear etiology. Extensive evaluation included home sleep test and laboratory polysomnography with multiple sleep latency testing (MSLT). Sleep apnea was ruled out, and the MSLT showed excessive sleepiness without confirmed narcolepsy. Multiple medications had been attempted without success. The patient had also tried continuous positive airway pressure (CPAP) which did not help. The patient had not been tried on modafinil/armodafinil. Although some physicians recommend modafinil in patients with a history of substance abuse with post recovery hypersomnia, in this case the substance abuse is more remote and is less likely related to the hypersomnia. Amphetamines were suggested but due to the prior substance abuse history, the physicians and patient wish to avoid these.

The physicians in this case have done a very thorough workup and have exhausted virtually all options for this patient. The diagnosis is not clear. The physician's opinion is that he has either type 2 narcolepsy or idiopathic hypersomnia. The patient has a remote history of substance abuse, and thus it is highly reasonable to avoid prescribing amphetamines. Modafinil and its derivative medication armodafinil are not considered to be amphetamines in the usual sense of the term. However, the biochemical mechanism of these medications is not well understood. Some studies (see reference 2) do suggest an amphetamine-like behavior of these drugs in their effect on cerebral dopamine with abuse potential. This correlated with the reviewer's experience that patients on modafinil and armodafinil experience a "high" that goes beyond the simple effect on daytime sleepiness. It is completely reasonable on the part of the patient to wish to avoid this medication if possible. 

Pitolisant is a newly Food and Drug Administration (FDA)-approved medication used to treat excessive daytime sleepiness in narcolepsy. It has been studied for the excessive daytime sleepiness (EDS) of sleep apnea and there are ongoing studies for its use in other conditions. It is unique in that is not a controlled substance and is felt to have low abuse potential.

Another option in this case might be solriamfetol (Sunosi), another non-amphetamine used for excessive sleepiness in the setting of narcolepsy and in sleep apnea. This would be a similar "off label" prescription and there is no reason to favor this medication over Pitolisant. 

There was sufficient evidence to support that Wakix was considered medically necessary treatment for the patient's condition.

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

The insurer's denial of coverage for Wakix 17.8 milligram (mg) tablet, quantity of 39 for 23 days is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing tooth #10. 
Treatment: Upper Partial Denture. 

The insurer denied the Upper Partial Denture. 
The denial is overturned. 

The patient is a female requesting a partial denture to replace missing tooth #10 (upper left lateral incisor). 

Yes, the proposed treatment with an upper partial denture is medically necessary. 
Missing an upper front tooth has made it harder for the patient to chew food. She claims food gets stuck in the missing tooth area. This is not good from a hygiene perspective and the need to keep her other teeth clean. Having the partial denture will help reduce the food getting lodged in the area of the missing tooth. This is not an issue of having enough teeth hitting together, it is an issue of preventing impacted food in the front of the patient's mouth from decaying other teeth and possibly causing the patient to lose more teeth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces for medical necessity.
 The denial was upheld. 

The patient is a female with moderate maxillary and mandibular crowding. The narrative states number (#) 6 and #11 are blocked out. The patient has a class I occlusion with 4-millimeter (mm) overjet and 10% overbite. The patient has treatment planned for orthodontics to align the teeth and correct the bite, but the treatment plan was denied for lack of medical necessity.
At issue is the medical necessity of Braces.

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

The requested health service/treatment of Braces is not medically necessary for this patient.
While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. Teeth #6 and #11 are crowded but they have erupted successfully. There are no indications of gingival recession or pathology from the tooth position of these teeth. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. The patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. The patient has a 4 mm overjet, but research shows an overjet does not affect oral health related quality of life unless it is greater than 6 mm. If the patient's teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health.
For these reasons the requested treatment of braces, is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atrial fibrillation

Treatment: inpatient admission 

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has a history of heart failure, non-ischemic cardiomyopathy (NICM), and paroxysmal atrial fibrillation status post transesophageal echocardiogram/direct current cardioversion

Per Milliman Care Guideline (MCG) 23rd Edition Guideline for Electrophysiologic Study and Intracardiac Catheter Ablation, this procedure is an outpatient one, with allowance of one night in the hospital at observational status. The patient underwent an uneventful electrophysiology study with ablation of atrial fibrillation. There were no complications. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted.

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

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain. 
Treatment: Durable Medical Equipment (Power Scooter [K0808 x 1]), Pre-service. 

The insurer denied the Durable Medical Equipment (Power Scooter [K0808 x 1]). 
The denial is overturned. 

The patient is a male with history of general disability with severe mobility limitations and wheelchair bound due to multiple medical issues include diabetes mellitus, multiple cerebral vascular accidents (CVAs), cervical and lumbar spine surgeries/fusions, gangrenous feet, peripheral neuropathy, chronic pain syndrome, etc. He continues to complain of severe low back and neck pain. Also, the patient has a past medical history of hypertension and congestive heart failure. 

The request is for K0808 - power operated vehicle (POV), specifically, Group II Motorized Scooter for those who weigh 451-600 pounds. The treating physician is requesting exception to the weight requirement because of patient's height. Lack of a workable scooter has affected his mobility.  Another motorized scooter was previously issued about five years ago but this was stated to be too small for patient because of his height and weight. 

Yes, the requested HD K0808 power operated vehicle (POV) is medically necessary as it is the most fitting supply which can safely be given to the patient. 

In this instance, the requested powered scooter is the most appropriate for the patient because of his height, as other scooters did not fit to help with his mobility. 

The patient has a history of general disability with severe mobility limitations and is wheelchair bound due to multiple medical issues including diabetes mellitus, multiple cerebral vascular accidents (CVAs), cervical and lumbar spine surgeries / fusions, gangrenous feet, peripheral neuropathy, chronic pain syndrome, etc.  He needs a powered scooter of the HD K0808 type as he has severe ambulatory limitations and his height requires that he will need a bigger scooter of the HD K0808 type.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right ankle fracture

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is upheld. 

This male patient has a history of diabetes.

This patient sustained his right ankle injury 2 days prior to presentation to the hospital. He underwent a limited procedure of syndesmosis repair. The fixation device was placed across the syndesmosis. There was no open repair of bone fractures. The duration of surgery was 70 minutes and with minimal blood loss. 

The patient did not have a fever nor problems with wound. His vital signs were stable. He was able to tolerate oral pain medication. There was no report of inability to use crutches. He did not require additional treatment for his diabetes nor have problems with his right knee replacement. He would have limited weight bearing. 

These findings do not substantiate the necessity of admission and length of stay as provided.  The patient underwent a limited procedure and had a satisfactory post-surgical course.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular Tachycardia (SVT).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient, a female with a past medical history significant for hypertension (HTN) and breast cancer, presented for an elective chemo port implant and went into supraventricular tachycardia (SVT) in the operating room (OR), broke with beta-blocker. The patient was seen in consultation by Cardiology. A two-dimensional echo revealed mildly reduced left ventricular (LV) function. The patient was advised to continue on the beta-blocker and follow-up as an outpatient to consider elective ablation.

No, the proposed treatment was not medically necessary.

The patient was admitted for an episode of supraventricular tachycardia (SVT) which responded to beta-blockers. The patient was started on oral beta-blocker and was advised to follow-up as an outpatient as per Cardiology consult. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left sided chest pain.
Treatment: full hospital admission.
The insurer denied coverage for full hospital admission.
The denial is upheld.


This is an adult male patient with no significant past medical history that developed left sided chest pain after eating a sandwich at work. Upon arrival to the hospital, vital signs were stable: blood pressure 144/81 and pulse was 81 beats per minute. Physical examination revealed no significant abnormality. Electrocardiogram (EKG) revealed normal sinus rhythm without ST (interval EKG) or T (interval of EKG) wave abnormalities. Serial serum troponin studies were not elevated. An echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) without wall motion abnormalities and perfusion stress testing revealed no cardiac ischemia. The patient was discharged on the day following presentation.

This patient presented with atypical chest pain and no significant past medical history. His pretest probability of coronary artery disease (CAD) is low. (1)  Utilizing the HEART score (History, EKG, Age, Risk factors, and troponin) he was considered low risk. (2)  Utilizing the TIMI risk score (thrombolysis in myocardial infarction) he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (3) 

Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (3) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.

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

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

Diagnosis: Recurrent Cerebral Vascular Accident (CVA).
Treatment full hospital admission
The insurer denied coverage for full hospital admission.
The denial is overturned.

This case involves an adult male who presented to the Emergency Department (ED) complaining of numbness to the right side of his face, fingertips, and right leg. He indicated he woke up the night before with no symptoms. The patient does have a past medical history that includes hyperlipidemia, hypertension, renal disease, and chronic kidney disease (CKD). He has a history of a lacunar infarct and prior transient ischemic attack (TIA). The documentation indicated he underwent an electrocardiogram (EKG) with a normal sinus rhythm. The physician indicated a stroke alert was activated upon arrival. He did undergo laboratory diagnostic studies. The computed tomography (CT) scan was negative. The vital signs revealed a blood pressure of 174/107. The physician did indicate he had clear speech with no facial droop or drift noted. The recommendation was made to treat the patient with oral aspirin. He was admitted to telemetry for further evaluation and treatment. 

The documentation does indicate the patient had an elevated potassium; however, it was responsive to potassium phosphate. He was recommended to undergo additional diagnostics. After admission the patient underwent a bilateral carotid Doppler and echocardiogram which were unremarkable. He continued with treatment that included atorvastatin as well as aspirin, heparin, losartan, metoprolol, amlodipine. The patient was discharged the following day with instructions to follow-up.

The patient present to ED with focal neurological deficits and a prior history of a TIA. Hence, he is at high risk for recurrent cerebral vascular accident (CVA). The workup seems appropriate. He was properly admitted for further evaluation. They completed the workup within 24 hours and discharged him. 

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

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache.
Treatment: Aimovig 70mg/ml SC SOAJ, Pre-service.
The insurer denied the Aimovig 70mg/ml SC SOAJ, Pre-service.
The denial is upheld.

The patient is a female with a history of migraine headaches. She has been under the care of a neurology practice. She reported a history of headaches since adolescence. The patient was averaging four to eight migraines per month. The note indicated that the patient had been unable to tolerate sumatriptan, rizatriptan (caused facial pain) and topiramate (caused "numbness and tingling in her fingertips). The patient had other complaints of always feeling cold, unintended weight gain, fatigue, aches and pains and thinning of her eye brows. Medications used by the patient included albuterol, medroxyprogesterone acetate IM q102, melatonin, Vitamin B and Vitamin D. Her medical history was otherwise notable for asthma. The patient's neurologist has since recommended treatment with Aimovig. 


No, the proposed treatment is not medically necessary.
The guidelines from the American Headache Society on the incorporation of calcitonin gene-related peptide (CGRP) based medications (into clinical practice) suggest introduction of calcitonin gene-related peptide (CGRP) based drugs for patients who have had trials of at least two level A/B rated prophylactic therapies for migraine. 

This patient is not noted to have met this requirement based on the information provided-- as she has not tried any such drug. There is otherwise a lack of credible literature showing that the use of Aimovig results in superior outcomes compared to the formulary drugs.  The patient is not noted to otherwise have any absolute (Food and Drug Administration listed) contraindications to the use of other validated prophylactic therapies for migraine.  Given that this request is not otherwise consistent with professional society recommendations, the use of Aimovig at this time would not be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cannabis use, behavioral, and mood symptoms

Treatment: residential mental health treatment

The insurer is denied coverage for residential mental health treatment

The denial is overturned. 

This male patient has a history of cannabis abuse disorder and disruptive mood dysregulation disorder.

In this case this patient was considered in need of 24-hour residential treatment as he needed time in this 24-hour inpatient therapeutic structured and supervised setting to learn coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, improve insight, decrease maladaptive and negative as well as physically aggressive behaviors, better control emotions, improve judgment and decision making, and decrease minimization of his problems.
If the patient were to leave this residential treatment prematurely, he likely would continue to use substances and continue to use maladaptive behaviors including aggression, so he required the entire time in this therapeutic structured and supervised treatment setting to decrease risk of harm to self and others, improve insight, and coping skills as well as emotional regulation, and try to better maintain abstinence when discharged from this 24-hour setting. 
As a result, the previous decision should be reversed, and coverage should be approved for inpatient substance residential rehabilitation treatment. If he were still in treatment, the insurer should do another review to assess further treatment needs and his progress.

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 the residential mental health treatment is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Leg amputation.
Treatment: Continued stay in a sub-acute rehabilitation facility.
The insurer denied the Continued stay in a sub-acute rehabilitation facility.
The denial is upheld.

The records report that the patient is a male with a history that includes poor vision,
diabetes and medical noncompliance/nonadherence. His functional baseline is independent, living alone in a 2nd floor residence with stairs to negotiate

The patient was hospitalized with sepsis and diabetic ketoacidosis. His hemoglobin
A1c (glycated hemoglobin) was greater than 16%. He was found to have gas gangrene in the left lower limb. He underwent a left below knee amputation. He was medically stabilized.

The patient was transferred to a skilled nursing facility for further care. Other history was noted to include stroke, seizures, coronary artery disease and hypertension.

It is reported that the patient is not able to manage the stairs he needs to return to the community. Barriers have been his eye surgery, which has limited or restricted the intensity of his therapy sessions. It is also noted that he does not have a prosthesis for his amputated left lower limb.

No, the Continued stay in a sub-acute rehabilitation facility is not medically
necessary.
The records indicate that the patient was at a supervision to independent level for his basic self-care and mobility. He had severe impairments in his vision as well as his recent
lower limb amputation status that were limiting his ability to reintegrate into the community. He had completed sufficient preprosthetic rehabilitation to return to the community, where completion of preprosthetic rehabilitation could be completed, and formal prosthetic rehabilitation started in the future once his residual limb has healed sufficiently for acceptance of an artificial limb, which is a very protracted process. There were no indications in the available documentation of medical or
nursing care requiring ongoing facility level care, such as complex wound treatment or intravenous pharmacotherapy. The medical necessity of ongoing skilled nursing facility care is not established in the available records.

The patient had plateaued at a level where he could have returned to the community with custodial level assistance and community-based care, including home services and rehabilitation. Ongoing care in a facility was not medically necessary.