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

This is a patient with a history of mild persistent asthma, non-compliant with controller medication, who presented to the emergency room (ER) with a 1 day history of a cough and fever with associated runny nose and 2 episodes of post-tussive emesis. The morning of admission she was noted to have increased work of breathing and chest tightness. She was using albuterol every (q)4 hours at home with progressive symptoms and worsening. 
The health plan's determination of medical necessity is overturned. Based on her failure of ER treatment with steroids and multiple nebulized beta agonists, inpatient hospital admission was medically necessary. She persisted with retractions and decreased air entry bilaterally as well cough and chest tightness. She was placed on albuterol every 2 hours. Such frequent nebulizer treatments would require more intense monitoring and would be considered appropriate for inpatient level of care. She continued with tachypnea, decreased air entry and retractions well into her admission. She needed continued close monitoring and care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a left below the knee amputation who has had changes to his residual limb so a new prosthetic has been prescribed. While the prosthetic has been approved the health plan has denied the vacuum pump, residual limb volume management and moisture evacuation system as not medically necessary. The health plan's determination is overturned. Given the patient's ambulatory and functional level, the patient requires the vacuum pump for the prosthesis to fit properly. He has used a vacuum pump system in his current prosthesis and reverting to a more basic system would be detrimental to his functional level and his health overall.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with genetic paraganglioma/syndrome, proven in genetic testing. He underwent removal of a paraganglioma of the larynx, and has several family members who have been similarly diagnosed as well. As tumors can occur anywhere, according to the provider, a positron emission tomography (PET) computed tomography (CT) was recommended for surveillance. The health plan's determination is upheld.

According to national guidelines,(1)surveillance of the patient with paraganglioma syndrome consists of magnetic resonance imaging of the head and neck region once every 3 years and magnetic resonance imaging or computed tomography of the thorax, abdomen, and pelvis once every 2 years. In 2014, the Endocrine Society (ES), the American Association for Clinical Chemistry (AACC), and the European Society of Endocrinology (ESE) released joint clinical practice guidelines for the management of pheochromocytoma and paraganglioma (referred to together as PPGL), recommend CT scanning as first line, rather than magnetic resonance imaging (MRI), but PET/CT was not recommended. (3) Based upon a review of the peer reviewed medical literature, a PET CT is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, History of hypertension

Treatment: Inpatient admission, diagnostic evaluation, medication management.

The insurer denied inpatient admission. That denial was upheld.

This patient presented to the Emergency Department with complaints of left-sided jaw pain as well as dizziness and stated he thought his blood pressure was high.  The patient has a past medical history to include hypertension.  He also stated he "took" an elbow to the right forehead the day prior while playing ball.  The vital sign included a blood pressure of 131/86 with a pulse of 90 bpm.  The patient was ambulatory as well as alert and oriented x3.  The recommendation was made to rule out a cerebrovascular accident (CVA).  It was recommended the patient undergo laboratory studies as well as imaging.  The physician indicated the exam did reveal 4/5 strength in the left upper and lower extremities with intact strength and sensation to the right side.  The diagnostic evaluations did not reveal any significant abnormalities.  It was noted the patient did have a fracture to the nasal bone that was age indeterminate.  The patient was admitted and continued treatment with further imaging.  The patient also underwent a chest x-ray showing the possibility of left atelectasis.  The patient was given aspirin, atorvastatin as well as folic acid, thiamine, and multivitamin.  A brain MRI as well as MRA studies were all performed.  They were normal.  The patient continued with treatment without further adverse events.  

According to current literature a patient may be admitted to inpatient services when there is evidence of severe new neurologic findings requiring inpatient care, the need for continuous intravenous infusion of platelet inhibitor, vasoactive, antiarrhythmic medication, or anticoagulation.  Additionally, a patient may be admitted when there is evidence of hemodynamic instability, severe or persistent vomiting or evidence of cerebellar, brainstem, or cerebral ischemia or hemorrhage.  Within the documentation none of the above was noted.  The patient presented to the Emergency Department complaining of jaw pain as well as dizziness.  He indicated he thought his blood pressure was high however, upon examination there was no documentation to support the patient was experiencing a hypertensive emergency.  There was no indication the patient could not have been observed and treated at a lower level.
Appeal type: Medical necessity
Decision: Upheld

The patient has a listed diagnosis of optic neuritis.  Records indicate she had an episode of left eye blurry vision, which was diagnosed as an optic neuritis.

The health plan's determination is upheld.  There is insufficient literature evidence to support the use of IVIG (Gammagard Liquid) in the treatment of optic neuritis.  This is not considered standard of care and is not generally recommended.  It is not part of any current societal recommendations or guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria

Treatment: Hormone suppression

The insurer denied Lupron depot. That denial was reversed

This patient is transgender female to male.  This request is for Lupron depot.  He has felt this way prior to age 9 and is completely transitioned socially for a number of years. He reports a distress associated with the mismatch between his gender identity and physical body.  In 2018 his breasts are at tanner 2-3 and pubic hair is at tanner 3. 

GnRH agonists such as Eligard, Lupron, and Supprelin are only FDA approved for central precocious puberty[1, 2] and prostate cancer.  While this would be off label use of the medication, The Endocrine Society clinical practice guidelines do support the use of GnRH analogs such as Lupron Eligard and Supprelin to suppress isosexual hormone production in patients with gender identity disorder [3, 4] such as this patient.  The treatment of this patient is consistent with the standard of care and is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder labral tear
Treatment: Fourth skilled PT modality - 97140

The treatment in question is not medically necessary.

The patient had undergone right shoulder labral and inferior glenohumeral ligament repair surgeries.  He was immobilized for four weeks and required physical therapy to restore range of motion, strength and function.  Manual therapy at the beginning of therapy was appropriate and indicated to initiate restoration of range of motion.  

As of the date in question, there were no documented indications for ongoing manual therapy.  There were no indications or expectations that the patient would not have been able to use heat independently for pain relief, or do exercises to improve range of motion.  There was no clear clinical rationale provided why manual therapy was required on this date of service, only documentation that it was provided by a physical therapist.  The service in question was not medically necessary based on the available records.
Appeal type: Medical necessity
Decision: Upheld

Diganosis: Elbow Pain
Issue under review: Manual therapy

Determination:
The manual therapy was not medically necessary.

The patient was having chronic and recurrent symptoms despite ongoing physical therapy.  There were no indications that she had any impairments that would have precluded an independent exercise and self-applied palliative modality program, e.g., using heat or ice, as of the time period under review.  There are no expectations that her clinical course and outcomes would have been significantly improved with ongoing manual therapy.  Manual therapy on a long-term basis has no proven role in the management of this condition, the mainstay of which is exercise, as far as conservative care is concerned.  The treatment in question was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

This case involves a female previously diagnosed with ductal carcinoma in situ as well as lobular carcinoma in situ and an intraductal papilloma.  She does have a family history of breast cancer and has undergone surgical intervention to include bilateral mastectomy.  MRI biopsy the following year showed granulomatous inflammation.  She discontinued the use of Tamoxifen 2 12 years after starting it.  The submitted documentation does include the MRI in question, which showed no evidence of malignancy.  According to the submitted documentation the patient had complaints of occasional left breast burning which prompted the bilateral breast MRI.

According to current literature from the National Comprehensive Cancer Network the clinical utility of an MRI and follow-up screening appointment with prior breast cancer is undefined.  It should generally only be considered in women whose lifetime risk of a second primary breast cancer is greater than 20% based on models largely dependent on family history, such as in those with the risk associated with inherited susceptibility to cancer.  Literature also details false positive findings on breast MRI are common.  The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome, and the patient would not be considered a good candidate.  Furthermore, the MRI of the breast would not be the most appropriate treatment, and would not likely be more beneficial than any other standard treatment/procedures.
Appeal type: Experimental/Investigational
Decision: Upheld

This case involves a female with a past medical history of ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS), intraductal papilloma, anxiety, hyperlipidemia and a family history of breast cancer.  The patient was status post bilateral mastectomies via mastopexies for left DCIS solid intermediate grade 1 cm, ER positive, PR positive and right focal classic LCIS and an intraductal papilloma.  The patient had a left reexcision for positive anterior margin 2 weeks later.  Both the DCIS and LCIS were found on MRI only.  The patient finished radiotherapy treatment at the end of the year, and started Tamoxifen the beginning of the next year.  MRI biopsy done 10 months after initial surgery showed granulomatous inflammation.  The patient stopped her tamoxifen 2 12 years after starting it.  The patient complained of occasional left breast burning sensation. A bilateral MRI was done the beginning of this year.  The patient has a strong history of LCIS and DCIS which was only found on MRI.  The patient had a family history of cancer consisting of her mother, her grandmother and her great maternal aunt.

Medical literature notes that Breast MRI may be useful in women with a prior history of breast cancer and suspected recurrence when clinical, mammographic, and/or sonographic findings are inconclusive. Patient did have a previous past history of DCIS and LCIS and an intraductal papilloma; had a previous mastectomy via mastopexies.  The patient did complain of occasional left breast burning sensation, however there was no indication that bilateral breast mammogram as well as ultrasound was inconclusive prior to the requested breast MRI.  MRI of the breast is not the best available treatment for the patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast pain
 
Treatment: MRI of the breast

The insurer denied the breast MRI. The denial was upheld.  A panel of 2 out of 3 reviewers determined it was not the best available treatment for the patient.

This female has a history of ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) and underwent surgical excision of her tumors followed by radiation therapy.  MRI and biopsy the following year shows granulomatous inflammation.  She complains of left breast burning pain.  MRI the beginning of this year showed no evidence of malignancy.  According to the American College of Radiology guidelines titled: "ACR Practice Parameter for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the Breast," MRI may be useful in women with a prior history of breast cancer and suspected recurrence when clinical, mammographic, and/or sonographic findings are inconclusive; and breast MRI is indicated in the surveillance of women with greater than or equal to 20% lifetime risk of breast cancer. 
This patient meets both of these guidelines.  She has a strong family of breast cancer in her mother, grandmother and maternal aunt.  In addition, she herself has a history of both LCIS and DCIS diagnosed on MRI in the past.  MRI screening is appropriate for this very high risk (>20% lifetime risk based on family history and personal history of breast cancer) female.
This testing is likely to be more beneficial than any other
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification 

Treatment: Inpatient detoxification Admission

The insurer denied the Inpatient Admission. The denial was reversed.
This is a male patient who was admitted to this inpatient substance detoxification treatment in early 2019 for alcohol/substance detoxification treatment. He had withdrawal symptoms including tremors, sweats, nausea, elevated blood pressure of 143/89, irritable mood, anxiety, teary eyes, sleeping problems, and agitation. He had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 11 and a Clinical Opiate Withdrawal Scale (COWS) score of 10. He was consuming alcohol and substances heavily. He had 11 past inpatient substance detoxification treatments and a past inpatient substance rehabilitation treatment. He had depression, as well as hypertension. He was unemployed. He was started on a Librium protocol with a taper for detoxification from alcohol during this admission. He also took Venlafaxine, in addition to Benadryl at that time. He was scheduled for discharge and opted for inpatient substance rehabilitation treatment at a later date.
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had been drinking alcohol daily and using cocaine and had reports of withdrawal symptoms. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require this 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings. This was evidenced by his continued use of substances despite past multiple inpatient detoxification treatments. It was reported that he had 11 prior detoxification treatments, as well as a prior inpatient substance rehabilitation treatment. He required detoxification medication, including Librium, which he took during this admission for alcohol detoxification treatment. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life-threatening withdrawal symptoms. The risk of life-threatening and complicated withdrawal such as delirium tremens can occur three to four days after alcohol use; therefore, he required this inpatient substance detoxification treatment with the recommendation for inpatient substance rehabilitation treatment. Additionally, he required inpatient detoxification treatment prior to inpatient substance rehabilitation treatment. He also lacked coping skills and the ability to identify relapse triggers. He had comorbid psychiatric issues including depression, as well as comorbid medical issues including hypertension. He was at risk for worsened withdrawal and required 24-hour inpatient hospital detoxification.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Issue with tooth #21
Treatment: D3347 Bicuspid tooth nerve canal repair, tooth #21
The D3347 - bicuspid tooth nerve canal repair on tooth #21 is medically necessary.
Tooth #21 is a functioning tooth in this patient's mouth; it is not a questionable tooth. It was deemed necessary to have a root canal procedure. There is no reason to not allow the procedure as the more teeth a person has in their mouth, the better. Just because the patient might have a partial denture is not a reason to not treat a functioning tooth in her mouth. It is not known when another tooth in that area might be lost, so the more teeth that can be treated and held onto, the better in the long run. Root canal procedure for tooth #21 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion, impinging overbite
 
Treatment: Orthodontic Care

The insurer denied the orthodontic care. The denial was reversed.

This patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class II malocclusion, asymmetric mandible, mild maxillary and mandibular crowding, posterior cross bite, excessive overjet and deep impinging overbite.  The orthodontist completed the HLD index as required.  

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage.  This automatically qualifying condition criterion is met and does support comprehensive orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The D8080 (braces) are considered medically necessary for this patient.  The carrier's denial of coverage for braces (D8080) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urologic Diseases
 
Treatment: Inpatient admission

The insurer denied the Inpatient admission. The denial was upheld. 
This case involves a male patient with a history to include hypertension, diabetes, bilateral knee degenerative joint disease, epididymitis, morbid obesity, and peripheral artery disease.  The documentation detailed the patient presented to the Emergency Department with complaints of bilateral knee pain as well as pain to the left testicle and lower abdomen. The patient stated he has had pain for a few weeks.  He did go to urgent care for evaluation six days prior for which he was prescribed levofloxacin.  The pain is exacerbated with walking and improved with sitting.  The patient also has a history of losartan use. However, it was discontinued two weeks prior due to hyperkalemia.  The physical exam revealed temperature was 98.4 with pulse of 106 bpm.  The patient's blood pressure was 162/76.  He was in no acute distress and there was slight tenderness to palpation of the paraspinous muscles.  The genitalia were grossly normal in appearance with slight tenderness to palpation of the left testicle.  There was also tenderness to palpation to the left lower extremity around the lateral and medial tendons.  There was no swelling and full range of motion.  The right lower extremity had the same exam findings and the physician detailed the patient should undergo possible imaging and multiple laboratory studies.
There is no support indicating this patient was having difficulty with urination or there was a renal disease requiring inpatient services.  Furthermore, the patient did respond to treatment within the Emergency Department and therefore the inpatient admission was not needed.
Based on the above, the medical necessity for the inpatient hospital services for acute level of care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System (Asthma, Allergies), Skin Disorders (Chronic idiopathic urticaria)
Treatment: Pharmacy/ Prescription Drug (Xolair)

Summary: This patient has a history of asthma, allergies and chronic idiopathic urticaria. The patient reported recurrent episodes of urticaria, occurring one hour after Cetirizine/meals, resolving with "cream." The patient was on Singulair and Zyrtec daily and Astelin twice daily. Treatment with Xolair is requested.

The insurer has denied coverage for Xolair as not medically necessary. The denial was upheld.

The patient has a diagnosis of chronic idiopathic urticaria. The medication has been FDA approved for patients such as this one. The patient has been treated with Singulair, Zyrtec, Astelin and cetirizine. The patient continues to have urticaria. The literature from 2019 indicates that current treatment guidelines recommend a stepwise approach starting with escalating doses of non-sedating antihistamines. However, the literature that was reviewed indicated the treatment was appropriate for patients who are 12 years of age and older. It was not recommended for patients under 12 years of age for the treatment of chronic spontaneous urticaria. There were no exceptional factors noted. Xolair is not considered medically necessary for this patient. The medication is not FDA approved for this patient's age group. The medical literature does not support the use of Xolair in the pediatric population as further studies are necessary.