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

Diagnosis: Cervical Spondylosis. 
Treatment: Physical Therapy. 
The insurer denied coverage for continued physical therapy. 
The denial is upheld. 

This is an adult with chronic neck pain. Cervical spine magnetic resonance imaging (MRI) scan performed, demonstrated chronic degenerative changes with "no herniated disc or spinal canal or foraminal stenosis." Treatment included physical therapy provided from last couple months.

The physical therapy treatment notes provide insufficient clinical information to support the medical necessity of continuing treatment. The clinical records do not demonstrate the medical necessity of continuing a structured out-patient physical therapy treatment program beyond the physical therapy visits that were previously approved. The treatment notes fail to demonstrate evidence of significant improvement to support continued therapy. For example, as of early this month, cervical/shoulder range of motion and cervical/shoulder motor strength had not significantly improved after more than 2 months of physical therapy. The provision of skilled physical therapy without evidence of significant improvement is consistent with maintenance treatment and additional physical therapy is not medically necessary.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, additional physical therapy is not medically necessary.

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

The medical necessity for continued physical therapy services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes, stroke, and dementia
Treatment: Personal care assistance (PCA) services, level II, 24 hours per day, 7 days per week (Monday through Sunday) (split shift)
The insurer denied coverage for PCA services, level II, 24 hours per day, 7 days per week (Monday through Sunday) (split shift)
The denial is overturned

This is an elderly male with multiple medical problems including hypertension, diabetes, stroke, and dementia. He lives with a non-relative in a private home. He is currently approved by the insurer for PCA 12 hours/day, 7 days/week (total 84 hours/week) and requesting a change to 24 hours per day, 7 days per week, (split shift).  

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." Instrumental Activities of Daily Living (IADL) range from total dependence to maximal assistance. Functionally, he requires maximal assistance for bathing, lower body dressing, ambulation, locomotion, and toilet transfer/use. Extensive assistance is needed for personal hygiene, upper body dressing, bed mobility and eating. He is essentially bed/wheelchair bound. He requires frequent bed repositioning for skin breakdown prevention; particularly since he is frequently bowel and bladder incontinent. The patient's declining and deteriorating activities of daily living (ADL) status and self-sufficiency are at a level and unpredictable as to require PCA services 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the PCA is unlikely capable of providing for the patient's functional needs with the ability to obtain uninterrupted 5 hours of sleep. As a result, the patient's health and safety would be more appropriately provided and maintained at home with PCA services 24 hours/day, 7 days/week split shift.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, PCA services, level II, 24 hours/day, 7 days/week (Monday - Sunday) (split shift) are medically necessary.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care assistance (PCA) services, level II, 24 hours per day, 7 days per week (Monday through Sunday) (split shift) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a male child who presented to the emergency department (ED) with a three-day history of shortness of breath. He had no history of asthma or wheezing. He was seen at Urgent Care two days prior to admission and diagnosed with a viral respiratory infection with acute otitis media. He was prescribed amoxicillin and discharged. He woke up one day prior to admission with a fever to 102 degrees Fahrenheit and shortness of breath. She took him to a nearby emergency department (ED) where he was treated with three CombiNebs. A chest x-ray was unremarkable. They were not discharged with prescriptions, so the patient's mother did not continue albuterol or steroids at home. He woke up on the day of presentation with worsening respiratory difficulty and subcostal retractions. He was taken to the primary care practitioner who referred them to the emergency department (ED) via Emergency Medical Services (EMS).
In the ED, the examination was significant for increased work of breathing, diminished aeration prior to CombiNeg, good aeration with scattered coarse expiratory wheezing following CombiNeb, tachycardia, tachypnea, accessory muscle use, benign abdomen, good perfusion, and non-focal neurologic exam. He was treated with a normal saline bolus, magnesium, albuterol every two hours (following three CombiNebs), and Solumedrol. He was given a diagnosis of status asthmaticus likely secondary to a viral upper respiratory infection (URI). At issue is the medical necessity of an inpatient stay.
 
The inpatient stay was not medically necessary.
This young male child with a history of a complicated COVID infection but no history of asthma presented to the ED with wheezing and respiratory distress. His examination was consistent with significant bronchospasm, including poor aeration, tachypnea, accessory muscle use, and tachycardia. He had been treated two days prior in urgent care, one day prior in a community ED, on the day of admission in the pediatrician's office, and with EMS en route to the ED. When he presented to the ED, he was still in distress with significant tachypnea, poor aeration, accessory muscle use, and borderline oxygen saturation. He responded to aggressive management, but not sufficient to discharge. He was only able to tolerate a two-hour interval between treatments. However, he was overall hemodynamically stable with no oxygen requirement and no significant dehydration. He did not require an acute inpatient admission and could have been safely managed in the hospital at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility
Treatment: Prometrium 200 mg (milligrams) capsule
The insurer denied the Prometrium 200 mg capsule
The denial is upheld.

The patient is a female undergoing fertility treatment. At issue is the medical necessity of Prometrium use in an ovulation induction intrauterine insemination (IUI) cycle. In this case, consideration must be given to the plan options: medroxyprogesterone, norethindrone and progesterone.

The subject under review is the medical necessity for the Prometrium.

The health plan's determination is upheld.

Prometrium is not medically necessary. Progesterone is an acceptable plan preferred drug. Although medroxyprogesterone and norethindrone are not used for luteal phase support, progesterone is a viable alternative medication. Therefore, the use of Prometrium is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Dupixent. 

The insurer denied: Dupixent. 
The denial is upheld. 

The patient is an adult male with a diagnosis of persistent asthma. The request is for Dupixent. 

The health plan denied the proposed Dupixent stating that the patient has not filled asthma medication on a regular basis, he does not have documentation showing uncontrolled asthma despite optimal therapy for at least six months, his eosinophil count must have been greater than 150 cells per microliter within the last six weeks, and there is no documentation showing two or more asthma flares in the past year that required medical management. The reason the physician is appealing the determination is to provide further documentation. 

The proposed treatment with Dupixent is not medically necessary. 

Per the Food and Drug Administration (FDA) label, Dupixent is indicated as an add-on maintenance treatment in patients with moderate-to-severe asthma aged six years and older with an eosinophilic phenotype or with oral corticosteroid dependent asthma. In the two pivotal clinical trials that led to the approval of Dupixent for certain patients 12 years and older, participants enrolled had a history of one or more asthma exacerbations that required treatment with systemic corticosteroids or emergency department visit or hospitalization for the treatment of asthma in the year prior to trial entry. In the third pivotal trial, participants enrolled had dependence on daily oral steroids in addition to regular use of high-dose inhaled steroids plus an additional controller. The baseline characteristics that predicted a better response to dupilumab included blood eosinophils greater than (>) 150 cells per millimeter cubed (mm3) as the asthma exacerbations and forced expiratory volume in one second (FEV1) were not significantly more improved than placebo in the group of participants with eosinophils less than (<) 150 cells per millimeter cubed. 

This patient has had chest tightness, shortness of breath, and wheezing almost on a daily basis. He has been using Advair one puff daily according to recent clinic note. This is not an optimal use of Advair. Optimal use of Advair is twice daily. The denial reason is consistent with the medical literature. The patient does not meet the Food and Drug Administration-approved indication for the use of Dupixent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity and obstructive sleep apnea, status-post sleeve gastrectomy with mixed hyperlipidemia.
Treatment: Trulicity 0.75MG (milligrams)/0.5ML (milliliters) SC (subcutaneous) SOPN (Solution Pen-Injector).
The insurer denied: Trulicity 0.75MG (milligrams)/0.5ML (milliliters) SC (subcutaneous) SOPN (Solution Pen-Injector).
The denial is upheld.

This is an adult female with morbid obesity and obstructive sleep apnea, status-post sleeve gastrectomy with mixed hyperlipidemia. Request for Trulicity is under review. The prior request was denied as the patient does not have type 2 diabetes. She has a body mass index of 61 kg/m2( kilograms/meters squared).

The proposed Trulicity is not medically necessary. 

This request is for Trulicity for weight loss for the management of obesity. Trulicity is not Food and Drug Administration (FDA)-indicated for obesity. The Endocrine Society on the management of obesity do not support the use of Trulicity in this clinical situation. Trulicity has risks, including nausea and vomiting. Therefore, no, the proposed Trulicity is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: inpatient admission
The insurer denied coverage for an inpatient admission.
The denial is upheld.

The patient presented to the Emergency Department (ED), due to hyperglycemia. The patient was admitted inpatient for further evaluation, treatment, monitoring and was given intravenous (IV) fluids and an insulin regimen. Vital signs in the ED were as follows: Temperature 36.3 degrees Celsius, heart rate (HR) 100, respiration rate (RR) 20, oxygen saturation 95% (percent) on room air, and blood pressure (BP) 141/90. Lab Studies revealed the following abnormalities: white blood count (WBC) 11.1, Hemoglobin 12.2, Hematocrit 35.6, Glucose 451, and Sodium 133. Urinalysis (UA) showed glucose > (greater than) 1000, and Ketones (+40). The patient received a total of Sodium Chloride 0.9% 3 L (liters) IV (intravenous) Bolus STAT (emergently), and regular Insulin 8 Units IV STAT. Endocrinology was consulted, and the patient was stable and discharged.

The patient failed to meet diagnostic criteria for diabetic ketoacidosis (DKA) based on the American Diabetes Association (ADA). The patient's blood glucose (BG) was greater than 250 milligrams per deciliter (mg/dl), (greater than 13.9 millimoles per liter (mmol/L)) but without an arterial potential hydrogen (pH) less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L). Admittedly the patient did have ketonuria and/or ketonemia. However, specifically, the patient's BG was 300, with no documented venous pH of 7.36. He had a normal carbon dioxide (CO2) or bicarbonate of 25, and a normal anion gap of 9. There was also no evidence of renal insufficiency or acute kidney injury. Therefore, the inpatient hospital admission 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 and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Strep pharyngitis
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

The patient presented with strep pharyngitis. The patient reported a sore throat and inability to tolerate oral intake due to emesis and pain. Despite triage in the emergency room (ER), the patient was admitted to the hospital for intravenous (IV) hydration and antibiotic to avoid progression toward septicemia. 

According to the Merck Manual Professional edition, "hospitalization is generally required in patients who have not returned to their baseline within four hours of aggressive emergency department treatment."

Furthermore, according to the Milliman Care Guidelines (MCG), inpatient admission is indicated as medically necessary for Systemic or Infectious Condition GRG - unmanageable nausea and vomiting. 

The patient was unable to tolerate oral intake times three trials and had unmanageable nausea and vomiting. Therefore, the admission should be approved.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care." (American Health Information Management Association, 2018)

"The main goals of treatment for Group A Strep (GAS) pharyngitis include reducing a patient's duration and severity of symptoms, preventing acute and delayed complications, and preventing the spread of infection to others." (Ashurst, J. V., & Edgerley-Gibb, L. 2022)

"Acute streptococcal pharyngitis warrants diagnosis and therapy to ensure prevention of serious suppurative and nonsuppurative complications. Life-threatening infectious complications of oropharyngeal infections, whether streptococcal or non streptococcal, may manifest with mouth pain, pharyngitis, parapharyngeal space infectious extension, and/or airway obstruction." (Tanz R. R. 2018)                                                         

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld


The patient is an adult who was admitted to the hospital with complaints of shortness of breath (SOB). The patient was admitted for asthma exacerbation. The patient was afebrile, in no acute distress, and hemodynamically stable. Lung exam revealed bilateral wheezing. Labs were unremarkable. There was no pneumonia.

The patient was treated with intravenous (IV) Magnesium, Fluids, Steroids and bronchodilators. The patient responded to the treatment in the Emergency Department (ED). The patient remained clinically stable and was discharged home the next day on oral (PO) meds and bronchodilators.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hours.

This patient improved rapidly after treatment in ED. She was discharged the next day after admission. This patient did not need acute inpatient hospitalization. She could have been discharged home on PO medications after a period under observation with close follow up as an outpatient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uterine fibroids
Treatment: procedure code 0404T x 1 Radiofrequency Ablation of Uterine Fibroids
The insurer denied coverage for procedure code 0404T x 1 Radiofrequency Ablation of Uterine Fibroids
The denial is overturned

This patient has a history of excessively heavy menstrual bleeding, documented anemia, cramping, clotting, pelvis pressure, and fatigue. The patient had multiple small intramural fibroids visualized and a suspected submucosal fibroid. The plan was for the patient to have a hysteroscopic myomectomy. The insurer has denied coverage for outpatient procedure 0404T x 1. 

Scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes. The patient was recommended to undergo a Uterine Fibroid Ablation Procedure (outpatient procedure 0404T).

According to Shifrin et al., (2021) "With the Sonata system, transcervical fibroid ablation (TFA) is an effective single-stage treatment option for non-pedunculated submucous myomata, and larger or deeper uterine fibroids (including fibroid clusters) for which hysteroscopic treatment is not suitable" 

Toub (2017) further concludes "The Sonata System is a promising treatment modality for uterine fibroids. As an incisionless, minimally invasive treatment that does not require general anesthesia or hospitalization, it has the potential for redefining the current paradigm for management of symptomatic fibroids."

Shifrin et al., (2021) further found two prospective clinical trials (FAST-EU (Fibroid Ablation Study-Europe) and SONATA) of sonography-guided TFA with the Sonata system, showed that TFA is an effective single-stage treatment option for non-pedunculated submucous myomata, and larger or deeper uterine fibroids (including fibroid clusters) for which hysteroscopic treatment is not suitable. 

The outpatient procedure 0404T x 1 has final approval from the appropriate regulatory bodies for this diagnosis. It is Food and Drug Administration (FDA) approved for ablation of fibroids. This patient is a good candidate for outpatient procedure 0404T x 1. She has a history of excessively heavy menstrual bleeding, documented anemia, cramping, clotting, pelvis pressure and fatigue. The patient had multiple small intramural fibroids visualized and a suspected submucosal fibroid. Most importantly, she is refusing other invasive surgical approaches. The outpatient procedure 0404T x 1 is the best available treatment for this patient currently. The adverse risks are not increased over the standard treatment/services. The medical literature supports the use of Sonata System for ablation of fibroids. This procedure is appropriate for the patient. It is the most beneficial as the patient is not agreeable to more invasive measures currently.                                                    

In summary, the denial of the outpatient procedure 0404T x 1 and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uterine fibroids
Treatment: procedure code 0404T x 1 Radiofrequency Ablation of Uterine Fibroids
The insurer denied coverage for procedure code 0404T x 1 Radiofrequency Ablation of Uterine Fibroids
The denial is upheld

The patient has a history of anemia. She is complaining of heavy menstrual bleeding. An ultrasound showed a submucosal myoma distorting the endometrial cavity and multiple small intramural fibroids. The provider is requesting coverage for Radiofrequency Ablation of Uterine Fibroids (The Sonata system).

The patient had a prior hysteroscopic myomectomy that controlled her symptoms for a period of time but now the symptoms have returned. This patient is complaining of heavy vaginal bleeding. She has a submucosal fibroid. It appears, based on submitted information, that an endometrial biopsy was performed but the result is not available to review. Depending on the result of the endometrial biopsy surgical management of the submucosal fibroid might be needed.

The Sonata system is Food and Drug Administration (FDA) approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids.

Symptomatic improvement is observed within the first three months post procedure. This improvement has been maintained at least through 24 to 36 months of follow-up. Depending on the result of the endometrial biopsy, the patient could undergo medical treatment or an endometrial ablation, a myomectomy or a hysterectomy that would lead to an immediate improvement in her condition. Those procedures for the management of fibroids have been used and are well established. Note that there are no studies documenting a better or safer outcome using the Sonata system versus a myomectomy, hysterectomy or an ablation. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. The outpatient procedure 0404T x 1 has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for outpatient procedure 0404T x 1. However, the outpatient procedure 0404T x 1 is not the best available treatment for this patient at this time. Depending on the result of the endometrial biopsy, the patient could be treated medically, or surgically with an endometrial ablation, a hysteroscopic myomectomy or a hysterectomy. The adverse risks are not increased over standard treatment/services. 

In summary, the denial of the outpatient procedure 0404T x 1 and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.