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

Diagnosis: Benign Intracranial Hypertension.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency ward with the complaint of double vision for several days and headaches. She had papilledema on examination. Magnetic resonance imaging (MRI) of the brain was normal. She was admitted and underwent lumbar puncture. The patient was started on acetazolamide and discharged to home.

No, the proposed acute inpatient admission was not medically necessary.

The patient presented with papilledema.  Otherwise, her neurological examination was normal. Magnetic resonance imaging (MRI) of the brain was normal. There was no documented vision field deficit. The acute inpatient level of care was not required. The diagnostic and therapeutic lumbar puncture as well as the initiation of acetazolamide could have been safely and effectively completed at a lower level of care. There was no loss of vision, intracranial pathology or other findings to support an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Migraines.
Treatment: Nurtec ODT 75MG Tablet.
The insurer denied the Nurtec ODT 75MG Tablet.
The denial is upheld. 

The patient is a female. She has been under care for a diagnosis of chronic migraine headaches. At the time of the patient's first visit, it was noted that the patient was noted to have had prior trials and failure of topiramate and propranolol. The patient was noted to have previously been treated with Botox for migraine prophylaxis with reported benefit. A recommendation had been made for continued therapy with Botox.  She has since been prescribed Nurtec for migraine prevention.

No, the requested treatment with Nurtec is not medically necessary.
The phase 2/3 study of Nurtec for migraine prophylaxis only evaluated patients with episodic migraine. The study excluded patients with more than 18 headache days per month (Croop et al). Nurtec has otherwise not been formally evaluated for use in patients with a history of chronic migraine (either as a preventative or an acute agent).  There also have not yet been any comparison studies completed to date supporting that Nurtec is more effective in migraine prophylaxis than other established therapies for the acute treatment of migraine. For all of these reasons, the request would not be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hyperglycemia.

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of type 2 diabetes mellitus, morbid obesity, hypertension, coronary artery disease, chronic kidney disease, and anemia.

The patient was admitted to the hospital by her Interventional Cardiologist for complaints of blood glucose over 400 milligrams per deciliter (mg/dL), shortness of breath, and for possible valve replacement. Laboratory results of glucose 301 mg/dL; blood urea nitrogen (BUN) 34 mg/dL; creatinine 3.2 mg/dL, pH venous 7.29, partial pressure of carbon dioxide 52. She had been to her Interventional Cardiologist as a consult for a coronary artery bypass graft, but was sent to the hospital for the hyperglycemia. She reported eating a meal and having soda prior to the test. She was found to have bibasilar crackles, systolic murmur, and elevated glucose. She was evaluated by Endocrinology, Cardiology, and Nephrology. After treatment, and once medically stable, the patient was cleared for discharge to home with follow-up instructions. The patient failed to meet any of the criteria for acute admission for hyperglycemia, based on Milliman care guidelines for Diabetic Ketoacidosis (DKA) or Hyperglycemic hyperosmolar non-ketotic state (HHS).  

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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8070 Braces; D8670 Monthly Visit x4, Pre-service
The insurer denied the D8070 Braces; D8670 Monthly Visit x4, Pre-service.
The denial is overturned.

The patient is a male with a severely handicapping malocclusion. Denial was with a score of 19 on the Salzmann index. The appeal is due to automatic qualifiers.

Yes, the proposed braces and four monthly visits are medically necessary.
The patient has two permanent anterior teeth in crossbite. Tooth #27 is in crossbite with #7. Tooth #22 is in crossbite with #10. Also, both lower permanent canines have gingival recession with loss of attachment (gum).  These are two automatic qualifiers that dictate the need for orthodontic treatment with follow up appointments. Orthodontic treatment is the only way to correct these problems. This case has medical necessity.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple stab wounds. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This female patient has a history of eczema. 

Based upon the information provided, the hospital inpatient admission is not approved as the patient could have been managed in an observation status.  The patient had multiple stab wounds that did not penetrate deep in the chest/lungs or abdomen- each of which were determined not to be life threatening and that did not require any acute intervention except for suture closure. Her vital signs were always stable. She was able to ambulate and take a diet. She required pain control.  She was managed with observation. Therefore, acute admission was not warranted but rather an observation status. This did not require an acute admission but could have been done on an observation status as the patient was stable and was discharged within 48 hours. 

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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myopic Choroidal Neovascularization.
Treatment: Lucentis 0.5MG Inj.
The insurer denied the Lucentis 0.5MG Inj.
The denial is upheld.

The patient is a male with myopic choroidal neovascularization OD (right eye) status post refractive surgery (LASIK) for whom coverage of Lucentis for dates of service is the subject of review.

Coverage was previously denied by the health plan, as it was not identified that the patient had tried or had a poor response to medications on the preferred drug list including Avastin, Mvasi, or Zirabev. On appeal, the provider states that while Lucentis has been FDA (United States Food and Drug Administration)-approved for the patient's diagnosis, Avastin has not been shown to be effective for the patient's diagnosis, and the provider was not willing to jeopardize the patient's vision.

No, the requested medication (intravitreal Lucentis) is not established medically necessary over the formulary alternatives, including bevacizumab (Avastin).
According to the American Academy of Ophthalmology, intravitreal anti-vascular endothelial growth factor (anti-VEGF) is considered as mainstay of therapy in myopic CNVM (choroidal neovascular membrane). The REPAIR and RADIANCE studies showed efficacy and safety of ranibizumab in this condition. The pro-re-nata (PRN) dosing of ranibizumab was found to be superior to PDT (photodynamic therapy) in the RADIANCE study. MYRROR study for aflibercept in myopic CNV (choroidal neovascularization) in Asian population has found it to be safe and effective. Bevacizumab is also used to treat myopic CNVM (choroidal neovascular membrane), but its intraocular use is not Food and Drug Administration (FDA)-approved.

Loutfi et al performed a meta-analysis of published literature comparing intravitreal ranibizumab with intravitreal bevacizumab for the treatment of myopic choroidal neovascularization. Early evidence suggested that intravitreal injections of ranibizumab are comparable to intravitreal injections of bevacizumab in the treatment of myopic choroidal neovascularization. Both treatments result in a statistically significant increase in visual acuity with high numbers of patients maintaining stable vision.

Similarly, Wang et al performed a retrospective and comparative study to compare the efficacy of intravitreal aflibercept and bevacizumab for patients with myopic choroidal neovascularization. They concluded that both aflibercept and bevacizumab can effectively treat choroidal neovascularization in high myopes. Intravitreal aflibercept had similar efficacy but less treatment number than bevacizumab for mCNV (myopic choroidal neovascularization) during 12-month period.

Therefore, as there as a review of the peer reviewed medical literature does not establish ranibizumab as being safer or more effective than bevacizumab in the treatment of the patient's condition, Lucentis is not established as medically necessary over the formulary alternatives.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Red Blood Cell Count (anemia).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with history of NSAID (nonsteroidal anti-inflammatory drug) use. He presented to the ER (emergency room) with anemia. As an outpatient, his Hgb (hemoglobin) was 7.3. He had recent black stool. He complained of some epigastric pain. He denied any NV (nausea and vomiting), hemetemesis, bright red blood per rectum or current melena.

The patient was hemodynamically stable. His Hgb (hemoglobin) was 7.4. He was transfused 2 units of PRBCs (packed red blood cells).

Day two, the patient's Hgb (hemoglobin) was 9.3. He was placed on PPIs (proton pump inhibitors) and seen by GI (gastroenterology). EGD (esophagogastroduodenoscopy) was scheduled.

On day two, three and four, there was no hemetemesis, melena or bright red blood per rectum.

On day five, Hgb (hemoglobin) was 10.7. EGD (esophagogastroduodenoscopy) revealed a duodenal ulcer, and the patient was discharged.

No, the Inpatient admission was not medically necessary.
The patient was hemodynamically stable, without evidence of active bleeding. He had no sepsis, coagulopathy, history of cirrhosis or any other significant co-morbidities. Therefore, treatment at a lower level care status was medically appropriate on day one. On day two, when his Hgb (hemoglobin) was up to 9.3, the patient was medically stable for discharge to outpatient care, or for EGD (esophagogastroduodenoscopy) at a lower level of care, and then discharged. Acute inpatient hospital stay was not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
As above, as a lower level of care status was medically appropriate, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying the acute inpatient hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder Pain. 
Treatment: Physical Therapy Services (97140, 97112, 97110). 

The insurer denied the Physical Therapy Services (97140, 97112, 97110). 
The denial is upheld. 

The patient is a female with history of cervicalgia, left shoulder pain with associated headaches secondary to left shoulder rotator cuff strain and left shoulder impingement.  She started physical therapy earlier in the year. 

The patient had 12 physical therapy (PT) sessions that included manual therapy, joint mobilization, neuromuscular re-education, therapeutic exercise, stretching, pain modalities and home exercise program. She had passive range of motion of 180 degrees, abduction at 170 degrees, internal rotation at 65 degrees and external rotation normal. At this level, she has met a range of motion and strength towards normal functionality. 

No, the proposed continued Physical therapy sessions for the dates of service were not medically necessary. 

The patient has not met all the criteria for continued physical therapy sessions based on the Official Disability Guidelines (ODG) for physical therapy because she had 12 physical therapy sessions that included manual therapy, joint mobilization, neuromuscular re-education, therapeutic exercise, stretching, pain modalities and home exercise program. She had passive range of motion of 180 degrees, abduction at 170 degrees, internal rotation at 65 degrees and external rotation normal.  At this level, she has met a range of motion and strength towards normal functionality that does not require further physical therapy sessions for the dates of service in question and the patient should be transitioned to a home exercise program for continued progression in her activities. 

Yes, the health plan has acted reasonably in this instance and its decision was with sound medical judgment which is in the best interest of the patient. 

The patient has a history of left shoulder pain and was requesting continued physical therapy for preservation of her functioning despite prior 12 physical therapy sessions with improvement. The patient can continue with a home exercise program.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower urinary tract symptoms
Treatment: Cystourethroscopy with Urolift Procedure
The insurer denied the Cystourethroscopy with Urolift Procedure
The denial is overturned

The patient is a male with worsening lower urinary tract symptoms despite daily tadalafil. Cystoscopy demonstrates obstructive prostatic lateral lobar hyperplasia and no middle lobe. Transrectal Ultrasound demonstrates prostatic volume of 43-45 grams and urodynamic study consistent with bladder outlet obstruction with high detrusor pressure and low urine flow rate.

The patient underwent cystoscopy and placement of 7 implants. The procedure was denied by the health plan as not medically necessary stating only operative report provided no documentation of prostate volume or medical treatment.

Yes, the Cystourethroscopy with Urolift Procedure (52441) was medically necessary.
The office notes confirm that the patient had worsening lower urinary tract symptoms despite medical therapy with daily tadalafil. A cystoscopy confirmed the absence of an obstructing median lobe and a transrectal US (ultrasound) demonstrated a prostate volume of 43-45 grams (below 80cc [cubic centimeters]), and patient without signs/symptoms UTI (urinary tract infection).

Furthermore, the use of UROLIFT for symptomatic BPH (benign prostatic hyperplasia) is recognized as a treatment modality in the AUA (American Urological Association) guidelines on benign prostatic hyperplasia, which states "PUL [prostatic urethral lift] should be considered as a treatment option for patients with LUTS/BPH [lower urinary tract symptoms/ benign prostatic hyperplasia] provided prostate volume 30 to 80cc [cubic centimeters] and verified absence of an obstructive middle lobe."

The documentation provided at the time of this review supports that the patient met medically necessary, and thus the requested health service should be covered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enlarged Lymph Nodes

Treatment CT (computed tomography) scan of the neck without and with contrast

The insurer denied coverage for CT scan of the neck without and with contrast

The denial is upheld

This patient with no significant past medical history presented to the Internal Medicine physician's office for an evaluation of left sided neck soft tissue pain. The patient had a nodule on the left side of the neck that was mildly tender. An ultrasound (US) revealed an abnormal left mid-cervical lymph node that was 1.6cm (centimeters) by 0.9 cm in size with abnormal architecture.  The physician recommended a computed tomography (CT) scan of the neck without and with contrast in order to evaluate the nodule.

The patient has no other symptoms.  It is unclear how long the lymph node has been present.

Based on clinical practice guidelines from American Academy of Otolaryngology Head and Neck surgery:  

	Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology, and the mass has been present for >=2 weeks without significant fluctuation or the mass is of uncertain duration. 

	Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on >=1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration of overlying skin. 

	Clinicians should conduct an initial history and physical examination for patients with a neck mass to identify those with other suspicious findings that represent an increased risk for malignancy. 

	For patients with a neck mass who are not at increased risk for malignancy, clinicians or their designees should advise patients of criteria that would trigger the need for additional evaluation. Clinicians or their designees should also document a plan for follow-up to assess resolution or final diagnosis. 

	For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at increased risk and explain any recommended diagnostic tests. 

	Clinicians should perform or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy. 


Based on presentation, it would be recommended to monitor the patient and follow up with examination or another ultrasound. ENT [ears, nose, and throat] evaluation could be considered if there is concern for persistent lymphadenopathy and concern for malignancy.  Medical necessity for CT scan of neck is not established.

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

The insurer's denial of coverage for a computed tomography (CT) scan of the neck without and with contrast is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Right Knee

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is the case of an adult female.  The patient had a history of asthma, deep vein thrombosis, hypertension, mitral valve prolapse, and previous patellofemoral joint replacement. The patient was admitted to the hospital for conversion right partial knee replacement to total knee with neuraxial block anesthesia. The patient's postoperative course was complicated by pain, nausea, and vomiting. She was cleared for discharge home.

The medical documentation submitted supports the need for admission and hospitalization. The information provided shows a revision knee procedure was completed. This by itself is more complex and has an increased risk of complication. 

The documentation showed the patient had ongoing problems with pain relief. She required multiple doses of Morphine and changes to the other analgesics. The amount of narcotic received could not be provided as an outpatient or lower level of care. This complaint did not resolve for a period of days and required ongoing management. In addition, the documentation described severe limits to ambulation, i.e., able to walk 5-10 feet. 

In conclusion based upon the problems with pain relief, the admission and length of stay was necessary. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Uterine Fibroids. 
Treatment: Transcervical uterine fibroid ablation with ultrasound guidance procedure. 

The insurer denied coverage for transcervical uterine fibroid ablation with ultrasound guidance procedure. 

The denial is overturned. 

The patient is a female with a history of uterine fibroids. She presented to the Gynecologist's office for a yearly examination. The patient had complaints of a two-year history of painful intercourse, menstrual cramping, frequent urination, pelvic pressure, and interrupted sleep. Ultrasound showed a single 4-5 cm (centimeter) fibroid. The patient is requesting coverage for the Sonata radiofrequency ablation. 
	
The Sonata System combines intrauterine ultrasound (IUUS) with radiofrequency (RF) ablation in a single handpiece. Sonata is suitable in an inpatient or outpatient setting and is intended for diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding. 

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, and this improvement has been maintained at least through 24 to 36 months of follow-up. Women treated with the Sonata pivotal trial experienced significant and durable reduction of fibroid-related symptoms, with low surgical reintervention rates over 3 years of follow-up. 

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

A transcervical uterine fibroid ablation with ultrasound guidance procedure is considered medically necessary for this patient. 

The insurer's denial of coverage for the transcervical uterine fibroid ablation with ultrasound guidance procedure is overturned. Medical necessity is substantiated.