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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pain Management. 
The insurer denied epidural steroid injections. 
The denial is upheld in whole. 

The patient is a female diagnosed with lumbar radiculopathy. Records indicate the patient underwent lumbar epidural steroid injections. Records indicate that coverage for these epidural injections were denied by the health plan as not medically necessary due to lack of conservative therapy.
The subject under review is the medical necessity for the epidural steroid injections.

The health plan's determination is upheld in whole.

No, the requested health service/treatment of Epidural Steroid injections is not medically necessary for this patient.
The patient was noted to have low back pain with radicular symptoms. However, the magnetic resonance imaging (MRI) does not show nerve compression at the level to be injected.
Additionally, the documentation submitted does not show that the patient tried and failed at conservative treatment to include exercise, physical or chiropractic therapy, and medications such as nonsteroidal anti-inflammatory drugs and/or muscle relaxants, or documentation of current participation in the a physical therapy or home exercise program after the first injection. The procedure report states the patient has tried physical therapy which only helps temporarily, however there were no therapy notes provided, dates of therapy, duration, and it was specifically stated that the patient reported symptoms starting about 2 to 3 weeks prior to this, and therefore the patient has not had six weeks of therapy for this condition. She was noted to have acute low back pain. It was also stated she preferred not to take non-steroidal anti-inflammatory drugs (NSAIDs) due to history of gastrointestinal (GI) ulcers  in the past, though there was no indication she had tried other medications.
Based upon the standard of care, it would not be considered standard of care to undergo injection therapy prior to having an appropriate course of conservative management tried and failed, typically including at least 6 weeks of physical therapy and/or chiropractic treatment combined with daily compliance with a home exercise program (HEP) in addition to appropriate pharmacological treatments.
Therefore, based upon the standard of care, medical necessity is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The insurer denied the Braces.
The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits.

Yes, the proposed braces are medically necessary. 

The patient has a deep, impinging overbite with severe soft tissue damage to the palate. This is an "automatic qualifier" according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Endocarditis
Treatment LifeVest
The insurer denied the LifeVest.
The determination is overturned in part.


This is a patient with immune thrombocytopenic purpura (ITP), status/post splenectomy (s/p) , recurrent endocarditis, s/p tricuspid valve debridement and repair, strep G aortic valve endocarditis, treated for 6 weeks with ceftriaxone. She is s/p aortic and tricuspid valve replacements. She had complete heart block, with a pacemaker, then a Cardiac Resynchronization Therapy (CRT) device placed. She was admitted for right ventricular (RV) failure and severe aortic insufficiency with aortic valve endocarditis. She had a redo aortic and tricuspid valve replacement. Postoperatively, she had complete heart block, and the placement of a pacemaker. There was an issue with a lead malfunction, but the lead was not replaced. She was discharged to rehabilitation. A transesophageal echocardiogram (ECHO) showed severe biventricular dysfunction, left ventricular (LV) ejection fraction (EF) 20%, mild mitral and tricuspid regurgitation. The aortic valve gradient was elevated, but the prosthetic valve appeared to open normally. There was a possible thrombus on the prosthetic tricuspid valve. She was discharged with a LifeVest. She was re-admitted with polymorphic ventricular tachycardia (VT), requiring shocks from the LifeVest. She underwent an upgrade of her pacemaker to a biventricular implantable cardioverter defibrillator (ICD). Medications were adjusted, and she was started on a milrinone infusion which was continued at discharge. She was referred for a transplant evaluation.
At issue is the medical necessity of the LifeVest
Question(s):
The wearable defibrillator was medically  necessary in part during the waiting period for an implantable defibrillator. She has a dilated cardiomyopathy due to valvular heart disease, with aortic and tricuspid valve replacements and EF 20%. She met criteria for an ICD, but at the time of discharge had a temporary condition preventing ICD implant - recent surgeries and treatment for endocarditis. There are no reasonable, medically appropriate alternatives. The LifeVest is appropriate, and in this case, successfully resuscitated the patient from ventricular tachycardia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Advanced Imaging Services (Including PET, MRI, CT). The insurer denied: MRI of Orbit (Eyes), Face and Neck without contrast (dye). 
The denial is overturned in whole.

The patient is male with chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis (CRMO /CNO) who presented four years prior to a left sacroiliac lesion. He also carries a diagnosis of Celiac, mild Crohn's ulcerative colitis, gastroesophageal reflux disease (GERD), and lactose intolerance. He has been evaluated by endocrinology for short stature.
He has had leg pains, which has prompted a magnetic resonance imaging (MRI) to look for body lesions. MRI was denied by the health plan based on a non-covered diagnosis.
The subject under review is the medical necessity for the MRI.

The health plan's determination is overturned in whole.

The requested treatment of MRI of the orbit (eyes), face, and neck without contrast (dye) are medically necessary for this patient.
MRI is the standard of care for this diagnosis to determine if there are CRMO lesions. The condition can be managed with non-steroidal anti-inflammatory drugs (NSAIDs) and biologics; however, these medications should only be given if a diagnosis has been made. Plain x-ray and even full-body bone scan will not show CRMO lesions in some patients. Therefore, MRI is the appropriate and acceptable imaging study for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo, diplopia and slurred speech. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. The denial is upheld. 

The patient is a female. She presented with the complaint of vertigo, diplopia and slurred speech. At presentation, she had right exotropia in primary gaze with limited adduction. She was admitted for possible stroke. MRI brain was negative. 

No, the inpatient admission was not medically necessary. 

The patient presented with acute vertigo. She was clinically stable and had a negative CT and MRI brain. The diagnostic studies, treatment, neurological evaluation and monitoring could have been safely and effectively managed at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain 
Treatment: Inpatient Hospital Stay 

The insurer denied the inpatient hospital stay. The determination is upheld. 

The patient has a history of tubo-ovarian abscesses in the past, deep vein thrombosis (DVT) and endometriosis, and uterine cancer. She presented to the emergency department (ED) for evaluation of pain and had a work-up including imaging, which showed a complex right adnexal collection. The patient was afebrile, with stable vital signs, normal blood tests and a non-focal exam. She was admitted for observation and intravenous (IV) antibiotics. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient stay is not medically necessary for this patient. She had a work-up including imaging, which showed a complex right adnexal collection. Given that the patient was afebrile, with stable vital signs and had a non-focal exam, that she was able to ambulate, take an oral diet and oral medications and that she did not have any acute conditions means that it was not medically necessary for her to be admitted to the hospital. Inpatient level of care, in this case, is not standard of care, supported by peer-reviewed literature or supported by professional organizations.
Appeal type: Medical necessity
Decision: Upheld

Cancer 
Radiation Therapy 

Diagnosis: Breast cancer 
Treatment: Proton beam radiation therapy 

The insurer denied proton beam radiation therapy. The health plan's determination is upheld. 

This is a woman with a history of a stage IV breast carcinoma. She developed brain metastases and was treated with stereotactic radiosurgery. She continued on chemotherapy. She then developed additional brain metastases as well as leptomeningeal metastases. Craniospinal radiation therapy was recommended to this patient to attempt control of this disease and improve her quality of life. The use of Proton Beam Radiation Therapy (PBRT) is under review. 

The proton beam radiation therapy is not medically necessary for this patient. There is a lack of any significant clinical trials published in peer reviewed journals supporting the benefit nor safety of proton beam radiation therapy over photon beam radiation for this clinical scenario. Additional studies are needed to determine the efficacy and safety of proton beam radiation for brain and leptomeningeal metastases. The recommended proton beam radiation does not meet medical necessity criteria and is not indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial was upheld in whole. 

The patient is a male with a past medical history significant for scrotal abscess caused by methicillin-resistant staphylococcus aureus (MRSA) who was referred to the emergency department because of complaints of scrotal swelling and erythema.
In the emergency department, the patient underwent a scrotal ultrasound that demonstrated no abscess.
On the initial evaluation, the patient was diagnosed with scrotal cellulitis, and given the previous history of MRSA infection, was started on intravenous (IV) Vancomycin.

When the patient was seen by the admitting physician his temperature was 99 Fahrenheit (F), blood pressure 114/57, respiratory rate 18, heart rate was initially 122 beats per minute (bpm) but came down quickly to 78 bpm. Oxygen saturation was 98% on room air. The patient was alert, interactive, in no distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The rest of the physical exam was unremarkable.

The patient was admitted to the hospital with scrotal cellulitis and received treatment with intravenous Vancomycin. The patient was evaluated by a urologist who diagnosed the patient with scrotal/perineal cellulitis. The urologist stated that there was no evidence of sepsis and recommended treatment with Vancomycin and switching to oral antibiotics once leukocytosis was resolved.
At the end of the hospitalization, the patient was discharged home in stable clinical condition with a prescription for oral Doxycycline and Bactroban ointment.

The health plan's determination is upheld in whole. 

The inpatient hospital admission was not medically necessary for this patient. The review of the medical records demonstrated that despite having scrotal cellulitis/folliculitis, the patient was afebrile and hemodynamically stable. There was no evidence of sepsis. There was no mention that the patient was immunocompromised, there was no evidence of altered mental status. There were no reports of failure of outpatient treatment. There was no evidence that the patient had any unstable concomitant conditions that would justify admission at the acute inpatient level of care.

Taking into consideration all these circumstances, the admission for monitoring was definitely warranted to ensure clinical stability, an adequate response to initial treatment with antibiotics, to rule out the scrotal abscess, and determine the regimen of antibiotics to be used after discharge. This could have been completed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth #6 misplaced 
Treatment: Braces 

The insurer denied the braces. The denial is overturned. 

The patient is a female. The request is for orthodontic benefits. 

The patient has tooth #6, her upper right canine, severely misplaced. It is palatal to teeth #5 and #7, meaning it is behind them. This will cause much trauma to teeth #6 and #27 which is below it, because they will hit each other upon chewing in an off center way. Fracturing and/or loosening of either tooth is a possibility. Also, with tooth #6 totally in the wrong position, there is no "canine guidance" on the right side. This means that during the chewing cycle, her teeth will not mesh properly and trauma is possible to other teeth on that side. Also, over time, temporomandibular joint (TMJ) issues could develop due to this severe malocclusion. This case has medical necessity.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Papillomatosis

Treatment: Opdivo (nivolumab) 

The insurer denied coverage for Opdivo (nivolumab).  

The denial is upheld.

This is a male patient with a history of recurrent papillomatosis of the larynx/lungs/hemoptysis and hypertension. His hematologist/oncologist treated him with 20 cycles of Avastin (bevacizumab). Without prior approval, his oncologist gave him 4 cycles of Opdivo (nivolumab). The patient had a recent computed tomography (CT) scan of the chest which revealed scattered pulmonary nodules and a consolidation dense in nature at the right lung base. 

Presently accepted treatments for this disease include a variety of drugs including acyclovir, other antivirals, interferon, human papillomavirus (HPV) vaccines, and Avastin (bevacizumab). The use of Opdivo (nivolumab) was based on minimal evidence from a small group of patients in a phase 2 study with a small number of patients and anecdotal reports on two other patients. Phase 2 trials are conducted in humans; the primary objective is a preliminary determination of therapeutic effectiveness and to find optimal dose ranges in patients for the disease being treated. Unfortunately, to date, there is no definite curative treatment available.

It cannot be said that the treatment is likely to be more beneficial than standard therapies. Further clinical studies will be needed. The evidence provided indicates that the use of Opdivo (nivolumab) cannot be given with confidence outside a clinical study and is deemed experimental at this point in time.  

The carrier's denial of coverage for Opdivo (nivolumab) should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Papillomatosis

Treatment: Opdivo (nivolumab)  

The insurer denied coverage for Opdivo (nivolumab). 

The denial is overturned.

This is a male patient with recurrent laryngeal papillomatosis, treated with endoscopic resection, and then with chemotherapy using Opdivo (nivolumab). 

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. In a small study by Creelan, et al. (2019) it was demonstrated that Opdivo (nivolumab) reduced frequency of surgeries and size of the papilloma. Opdivo (nivolumab) does not have final approval for use in this disease. However, juvenile onset recurrent respiratory papillomatosis (JORRP) is a human papilloma virus mediated progressive benign neoplasm that affects children and young adults. Primary management consists of regular surgical debulking to maintain airway patency and vocal function.  Like condyloma acuminata, JORRP is associated with immune dysregulation, and T cells isolated from papillomas express an anergic phenotype. This is rare disease, and there are very limited studies in regard to treatment. Large studies to support use of any treatment would not be feasible.     

This patient is a good candidate for Opdivo (nibolumab). It is the best available treatment for this patient at this time. The use of Opdivo (nivolumab) is showing promising results in cases of recurrent laryngeal papillomatosis. This service is likely to more beneficial than any standard treatments/procedures for this patient. He has had surgery and was started on Opdivo (nivolumab) which resulted in improvement. Seeing that he has responded, the use of Opdivo (nivolumab) is acceptable to use in further treatment.

The carrier's denial of coverage for Opdivo (nivolumab) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Papillomatosis

Treatment: Opdivo (nivolumab)  

The insurer denied coverage for Opdivo (nivolumab).  	

The denial is overturned.

This is a male patient who is being treated for recurrent respiratory papillomatosis, with larynx and lung involvement, and hemoptysis. He is status post multiple excisions with Opdivo (nivolumab). The patient is also status post Avastin (bevacizumab) x 20 cycles. 

Per the National Cancer Institute Center for Cancer Research. (2018), "Recurrent respiratory papillomatosis (RRP) is a rare disease caused by infection with human papillomavirus (HPV). In RRP, noncancerous tumors called papillomas grow in the respiratory tract (voicebox, windpipe, lungs) where they can cause voice changes or make breathing difficult. There is no cure for RRP, and the main treatment is to surgically remove tumors from the airway or vocal cords. The tumors vary in size, grow very quickly and may grow back after they have been removed, meaning patients often need to have multiple surgeries."     

"Recurrent respiratory papillomatosis is a human papillomavirus (HPV)-driven disorder that causes substantial morbidity and can lead to fatal distal airway obstruction and post-obstructive pneumonias. Patients require frequent surgical debridement of disease, and no approved systemic adjuvant therapies exist." (Allen, et al. 2019).     

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Opdivo (nivolumab) does not have final approval, however, it is an uncommon condition and clinical trials may not be feasible in this case to require final regulatory approval. This patient is a good candidate for Opdivo (nivolumab). He has already received this medication for treatment, and has shown a response to it. As this is a rare disease, and the fact there are no approved therapies, continuation would be considered appropriate.

Given that the patient appears to be responding, and there are unmet medical needs in this condition, the use of Opdivo (nivolumab) in this case is considered likely to be more beneficial than any other standard therapies, particularly as this patient has seen an improvement.

The carrier's denial of coverage for Opdivo (nivolumab) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of tobacco abuse, diabetes mellitus type 2 (DM2), hepatitis C, intravenous drug use (IVDU) and schizoaffective disorder and was admitted with complaints of (c/o) a swollen, erythematous left forearm associated track marks with weeping abscesses. Vital signs were notable for a pulse of 108, temperature (T) 100 degrees Fahrenheit. The physical exam showed a swollen, erythematous left forearm and associated track marks with weeping abscesses. Lab work was notable for a white blood cell count (WBC) of 13, glucose 662, which decreased after intravenous fluids (IVF). An elbow radiograph showed soft tissue swelling but no evidence of osteomyelitis. The patient was diagnosed with cellulitis and hyperglycemia and treated with IVF, insulin, IV antibiotics, blood cultures, arm elevation and possible incision and drainage (I&D). The patient left against medical advice (AMA) in stable condition. At issue is the medical necessity of an inpatient stay.
The inpatient hospital stay was not medically necessary. The patient presented to the ED with c/o swollen, erythematous left forearm associated track marks with weeping abscesses. The patient did not have a significant fever, did not appear toxic, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, severe leukocytosis, animal or human bite with extensive damage, high risk location (face, neck, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with IVF, insulin, IV antibiotics, blood cultures, and arm elevation, and this could have been safely provided at a lower level of care. The patient responded to treatment with decreased tenderness, erythema, swelling and pain, both objectively and subjectively. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary.
Inpatient Hospital.

Diagnosis: ureteral stone.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with a history of hypertension (HTN) who presented to the hospital with R (right) flank pain one day after a previous emergency room visit in which she was diagnosed with a 3 millimeter (mm) mid right sided ureteral stone with hydronephrosis.

The inpatient admission in this case was not medically necessary based on documentation provided. The patient presented with renal colic. The patient was not hemodynamically unstable. She did not have acute renal failure, bilateral ureteral obstruction or unilateral obstruction of a solitary kidney. She did not have severe pain or vomiting that required acute inpatient management. She did not have a documented urinary tract infection. She did not require IV hydration beyond which could have been provided at a lower level of care. She did not require an inpatient surgical procedure. There was no documentation of another condition, treatment or monitoring that required an inpatient admission. The patient could have been safely and appropriately treated at a lower level of care.