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

Diagnosis: Breast pain.
Treatment: Breast implant removal.
The insurer denied the breast implant removal .
The denial is upheld.

This is an adult female with breast pain.  She had bilateral breast augmentation with saline implants sub-pectoral.  She is now having breast pain and discomfort.  She complains of neurologic symptoms.  Breast implant removal is planned.

No, the breast implant removal is not medically necessary.

The requested breast implant removal are related to a previously cosmetic surgery.  This patient has saline implants.  Although some concern has been raised that silicone breast implants may cause systemic symptoms, saline implants are not thought to cause implant-related illness.  Moreover, even silicone implants are unlikely to cause any systemic symptoms.  According to a 2016 study by Balk et al.: "The evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes.  Better evidence is needed from existing large studies, which can be reanalyzed to clarify the strength of associations between silicone gel implants and health outcomes."  According to a 2019 review by Rohrich et al.: "To the best of our body of scientific knowledge to date, there have not been any concrete or evidence-based studies or peer reviewed data concerning the formation of a new syndrome: 'silicone implant illness' ".  Lastly, according to the Food and Drug Administration (FDA), "There is no apparent association between silicone gel-filled breast implants and connective tissue disease, breast cancer, or reproductive problems".

Peer studies do not support removal of this patient's implants and capsulectomies to prevent or treat a systemic inflammatory condition.  Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, and/or interference with the diagnosis or treatment of breast cancer.  The American Society of Plastic Surgeons (ASPS) position paper goes on to say that insurance carriers "respond thoughtfully and with compassion on an individual basis" for several other conditions including "mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography)." Cosmetic/elective breast implant surgery is associated with risk and complications. Capsular contracture is a benign condition.  Although contractures can be painful, they do not pose a health risk or danger.  The surgery is not medically necessary to prevent a disease or illness or to treat a functional problem.  The patient's clinical presentation does not support that the breast implant removal is considered to be a medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male for which an inpatient level hospitalization is under review. There was a past medical history of an NSTEMI (non-ST elevation myocardial infarction) and a recent percutaneous intervention of the right coronary artery. There was report of ongoing occasional chest pain not related to exertion and a known LAD (left anterior descending) stenosis. He was admitted electively for percutaneous intervention of the LAD.

The patient's creatinine was normal. The patient's LVEF (left ventricle ejection fraction) was normal. His vital signs were normal. He underwent successful an uncomplicated percutaneous intervention. He was monitored. There were no cough cases, and he was discharged.

No, the inpatient admission was not medically necessary.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, CHF (congestive heart failure), hemodynamic instability, CVA (cerebrovascular accident), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high risk medications requiring prolonged in-hospital monitoring. In this setting, medical necessity for an inpatient level hospitalization has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Onychomycosis

Treatment Jublia

The insurer denied coverage for Jublia

The denial is upheld

The patient has a clinical diagnosis of onychomycosis affecting one toenail.  The patient is purported to have failed two courses of terbinafine and only found to have the condition resolve with Jublia previously, only to recur now.  The requested medication is Jublia.  

Based on the documentation provided Jublia is not considered medically necessary.   There is no documentation included to demonstrate objectively that the diagnosis is in fact onychomycosis (nail scraping potassium hydroxide (KOH) or culture).  The failure of oral terbinafine or topical ciclopirox is not documented and thus it cannot be determined the dosing or duration of treatment used.  The documentation does not provide potential contraindications to alternative therapies which have been shown to treat onychomycosis that would necessitate Jublia.  Furthermore, there are no comparative, controlled studies showing that Jublia has a superior efficacy profile to commonly used and available alternatives.

According to the current dermatology literature, the preferred medicines such as ciclopirox solution and terbinafine are effective treatments for the management of tinea unguium (1, 2).  Gupta et al writes "Data from the pivotal US trials have demonstrated that ciclopirox nail lacquer 8% (percent) topical solution is significantly more effective than placebo in the treatment of onychomycosis" (3).  Bohn et al writes "Ciclopirox nail lacquer is a topical product that provides an active fungicidal agent in a delivery system capable of promoting nail penetration" (4).

After review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Jublia prior to alternative therapies.   The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Jublia is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leukocytosis 

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a past medical history significant for chronic kidney disease, and presented to the emergency department with fever, weakness, and elevated white blood cells (WBC).  Vitals on presentation included: Temperature 99.8 Fahrenheit, Blood Pressure 135/80, Pulse 80, Respiratory Rate 16, oxygen (O2) saturation 97% (percent) on room air. Laboratory values were notable for the following: white blood cell count (WBC) 11.82, hemoglobin (Hgb)-13.2, hematocrit (Hct)-38.6, glucose-174, creatinine-1.25, lactic acid-1.7, urinalysis was negative. The patient was admitted for possible fever and leukocytosis as an outpatient. Computed tomography (CT) scans were negative. The patient had previously tested COVID (coronavirus) negative on multiple occasions. The patient remained afebrile, hemodynamically, and clinically stable. The patient was scheduled for discharge following evaluation in the emergency department, but family member was "uncomfortable" taking him home. He was discharged following a negative diagnostic work-up.

According to medical records, patient presented with fevers and weakness at home. Otherwise, he was afebrile, hemodynamically stable; and unremarkable laboratory results except for a mildly elevated WBC (11.8). Diagnostic evaluation was negative, and no treatment was initiated or indicated. Based on above findings, patient fulfilled criteria for observation level of care; he did not meet criteria for acute inpatient admission. 

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

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

Diagnosis: Dry Eye Syndrome

Treatment: Restasis

The insurer denied coverage for Restasis.

The denial is overturned. 

The patient has diagnoses of keratoconjunctivitis sicca and Sjorgen's Syndrome.  Restasis resulted in improvement in symptoms.

As summarized in UpToDate "The benefits of topical cyclosporine for patients with SS 
[Sjorgen's Syndrome] were shown in a series of randomized trials, which compared it with placebo and with artificial tears, and also in observational studies. Clinical benefits in both subjective and objective measures of dry eye and in changes in the corneal surface occur in approximately 60 to 75 percent of patients with twice-daily dosing, and treated patients show a decrease in infiltrating T-cells [protects the body from infection] in conjunctival biopsies and other improvements in histology."

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

Based on the above, the medical necessity for the Restasis for the treatment of dry eye syndrome is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crown replacement (damage tooth #19). 
Treatment: D2750 white glass with high gold content crown to tooth number 19. 

The insurer denied coverage for D2750 white glass with high gold content crown to tooth number 19. 

The denial is upheld. 

Upon review of the documentation provided which includes a single copy of periapical radiograph, and insurer correspondence, it appears that this patient presented to the dentist for crown placement on endodontically treated #19. The documentation states that a crown was approved and placed by her dentist but was loose and came off. This prompted the patient to change dentists and seek care with another dentist. The patient states that the dentist tried to adjust the crown, but this was not successful and therefore he recommended a new crown. 

The objective documentation provided for review is one copy of a periapical radiograph  which indicates an endodontically treated tooth #19 with crown preparation. There is no evidence of pathology. In this case, the main issue is not whether a crown is indicated, in fact the insurer already approved a crown for this tooth, and further, a crown was fabricated, but whether another crown is medically necessary. 

In this case, it cannot be determined whether the original crown was defective as there is no objective information to support this assertion. There is no information as to whether the patient had discussions on a remake of the crown with the original dentist where the service was covered and originally delivered. What is noted is that the patient of her own accord changed dentists with the new dentist recommending a new crown. 

D2750 white glass with high gold content crown tooth #19 is not medically necessary as the documentation is insufficient to justify or substantiate the patient's assertion that the original crown was defective. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the D2750 white glass with high gold content crown to tooth number 19 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: S/p (status post) COVID-19 infection. 
Treatment: Long-term custodial care, pre-service. 
The insurer denied the long-term custodial care. 
The denial is overturned. 

The patient is a female with history of confusion and general debility with abnormal gait, decreased balance and ambulation after COVID-19 (coronavirus) infection. She has relevant history of depression, Alzheimer's disease, hypertension, hypothyroidism, ulcerative colitis, etc. 

The patient is unable to follow commands due to her state of confusion, but she is participating in therapy. 

Prior to admission, the patient lived with her husband in an apartment building with elevators. She had HHA (home health aide) Monday to Friday for 5-6 hours per day, and she was using rolling walker for ambulation. Her husband is unable to help in her ADLs (activities of daily living). 

The patient requires maximum assistance for most ADLs. 

Transfer to a nursing facility for long-term custodial facility was denied by the health plan due to lack of enough clinical information, with an appeal providing further clinical information. 

Yes, the long-term custodial care is medically necessary. 

Post-Covid infection, the patient has general debility, gait imbalance, ambulation difficulty and confusion while requiring maximum assistance for most ADLs. 

The patient needs to be in a long-term custodial care, because she needs help with daily living activities including eating, which has led to loss of weight, dressing, bathing, transferring and ambulating, while requiring rehabilitation in OT (occupational therapy) and PT (physical therapy) for the purpose of improving function to an extent that might allow for a more independent existence. 

As noted above, the transfer to a long-term custodial care is medically necessary with clinical evidence of general debility and decreased ADLs associated with confusion. 

The patient will not be able to achieve any tangible improvement in a lower level of care, such as outpatient rehabilitation or home rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Throat Pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient had a past medical history significant for delusional disorder who presented to the emergency department for complaints of pain and selling of her pharynx.  Vitals on presentation included: Temperature 97.8 Fahrenheit, Blood Pressure 148/83, Pulse 95, Respiratory Rate 17, oxygen (O2) saturation 100% (percent).  Laboratory results included the following: white blood cell count (WBC) 14.3, Hemoglobin-15.2, Hemeatocrit-44.4, creatinine-0.78, glucose-110, and ESR [erythrocyte sedimentation rate]-21. 

The patient was admitted for throat pain. Infectious Diseases consulted and patient was empirically started on intravenous antibiotic (vancomycin, acyclovir, and Unasyn). Chest x-ray (CXR) was negative. Magnetic resonance imaging (MRI) of neck showed edema within soft tissues of the lower face and anterior neck and mild enlargement of submandibular glands. The patient remained afebrile, hemodynamically and clinically improved. The patient was discharged to continue oral antibiotics (Augmentin and doxycycline) as an outpatient. 

According to documentation, the patient presented with throat pain. Otherwise, patient was afebrile, hemodynamically stable with no evidence of airway compromise. Laboratory results were unremarkable except for a mildly elevated WBC. She had no co-morbid conditions, and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management. 

Prior determination of denial of acute inpatient admission is upheld. 

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

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

Diagnosis: Ischemic stroke. 
Treatment: Subacute rehabilitation services. 

The insurer denied the subacute rehabilitation services. 
The denial is upheld. 

The records report that the patient is an adult male with a history that includes coronary artery disease (with percutaneous coronary intervention), heart failure (with 20% ejection fraction), hypertension, diabetes and polysubstance abuse. 

The patient presented to the emergency room with left arm numbness and difficulty with depth perception.  He had stopped taking his antiplatelet therapy and other medications.  He had last used cocaine two weeks earlier.  He also reported concern that a friend might be "poisoning his drinks."  He reported that his sister had changed the locks at his mother's apartment where he had been living.  Examination showed impaired orientation and memory.  Muscle strength, sensation, reflexes and coordination were reported to be intact.  Work up showed a subacute hypodensity in the right occipital lobe.  The impression was an ischemic stroke likely induced by cocaine use.  He was admitted to the hospital.  He was managed medically.  He was cleared for a regular consistency oral diet.  Skin was intact. 

The patient was transferred to a skilled nursing facility for further care.  There was subjective left greater than right-sided weakness.  He was noted to have poor vision at night.  He was on a regular consistency oral diet.  He was noted to be continent of bowel and bladder.  On examination, strength was rated as 4/5 in the upper limbs and 3-/5 to 4-/5 in the lower limbs.  There were no contractures.  There were scabs on the left knee.  Skin was otherwise intact.  There was no edema. 

The patient was noted to have stable anemia.  He was on medical management for his diabetes, which was continued without changes.  A nephrology consultation was placed for his acute on chronic renal insufficiency with a blood urea nitrogen (BUN) of 36 and creatinine of 1.55.  His secondary stroke prophylaxis therapy was continued. 

The patient denied pain.  He was noted to be ambulating independently.  His creatinine was 1.85.  Metformin was discontinued.  Nephrology and endocrinology consults were pending.  He was encouraged to increase his fluid intake.  His anemia was stable. 

The patient was discharged from the facility to the community. He was to continue dual antiplatelets and statin therapy. 

The health plan denied coverage of custodial care at the facility, indicating that the patient's care needs could have been met in the community setting and long-term care was not required permanently. 

No, the subacute rehabilitation services from were not medically necessary. 

The patient had chronic medical issues that were sufficiently stable for outpatient follow-up.  He had no functional impairments needing inpatient rehabilitation.  He was reported to be ambulating independently.  There are no indications in the available records that the patient required ongoing care in a facility.  The services in question were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CHF (congestive heart failure) exacerbation. 
Treatment: Inpatient admission. 

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

The patient is an adult male who has a past medical history significant for atrial
fibrillation, HTN (hypertension), aortic valve endocarditis, moderate to severe mitral
regurgitation, CHF (congestive heart failure), chronic kidney disease,
asthma/COPD (chronic obstructive pulmonary disease), tobacco abuse and
polysubstance abuse. He presented to the ER (emergency room) with worsening
dyspnea and edema. The patient had a history of non-compliance with medical
therapy. 

The patient's physical examination revealed bilateral rales. ECG 
(electrocardiogram) revealed atrial fibrillation with non-specific ST changes and left
anterior hemiblock. His renal function was abnormal, with BUN (blood urea
nitrogen) of 47 and creatinine of 1.56. Chest X-ray was consistent with CHF
(congestive heart failure). 

The patient was started on oxygen, IV (intravenous) Lasix and admitted for
management of acute exacerbation of CHF (congestive heart failure). The patient
was diuresed with improvement in his symptoms and edema. Echocardiogram was
performed, revealing EF (ejection fraction) of 50-55% with mild to moderate mitral
regurgitation. He was continued on medical therapy and received counseling
regarding compliance and avoidance of drug use. The patient was discharged
home with a plan for outpatient follow-up. 

Yes, the inpatient admission was medically necessary. 

The patient presented with symptoms of acute CHF (congestive health failure)
exacerbation, with known diastolic dysfunction, CHF (congestive health failure) and
mitral valve disease. His course was more complicated, given the atrial fibrillation,
as well as chronic kidney disease. Although the usual course of hospitalized
patients with CHF (congestive health failure) exacerbation is brief, with expected
discharge in 24 hours with adequate diuresis, there are certain subsets of patients
that require extended periods of hospitalization for control of their symptoms, such
as the case in this patient. 

This patient with multiple co-morbidities presented with CHF (congestive health
failure) exacerbation. He was appropriately treated with IV (intravenous) diuresis.
He required close monitoring of his CHF (congestive health failure) and renal
function, given the underlying kidney disease. Given this presentation, acute CHF
(congestive health failure), as well as multiple risk factors, co-morbid conditions, it
would be consistent with the current standard of care that this patient be managed
in an inpatient setting. Therefore, the requested inpatient admission was medically
necessary and appropriate for this patient's care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite with gingival attachment loss of the lateral incisors

Treatment: Braces (comprehensive orthodontic treatment of the adolescent dentition)

The insurer denied coverage for braces (comprehensive orthodontic treatment of the adolescent dentition).

The denial is overturned. 

This male patient has no documented history.

Upon review of the submitted documentation, 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, an HLD (handicapping labio-lingual deviation) index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating Orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.

Regarding the validity of the Handicapping Labio-lingual Deviation index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.  

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. Comprehensive orthodontic treatment is medically necessary.

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

The carrier's denial of coverage for the braces (comprehensive orthodontic treatment of the adolescent dentition) is overturned. The medical necessity is substantiated.