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

Diagnosis: Alcohol Withdrawal
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult male patient presented with generalized fatigue. The patient complained of two months of progressive weakness, nausea, vomiting, weight loss, and jaundice. The patient's vital signs revealed temperature 98.1, pulse 101, respiratory rate 16, blood pressure 158/101 and oxygenation saturation 99%. His exam was unremarkable. The patient's pertinent labs revealed: alcohol greater than 36, white blood cells (WBCs) 15.3, hemoglobin 98.3, COE = 16, potential of hydrogen (pH) -7.23, prothrombin time 17, international normalized ratio (INR) 1.37, lactic acid 10.6, total bilirubin 6.2, aspartate aminotransferase (AST) 189, lipase 74, alkaline phosphatase 296, and direct bilirubin 4.8. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 12. Ultrasound showed enlarged liver consistent with fatty infiltration. The patient was admitted with alcohol withdrawal. Plan of care included intravenous Protonix. The abdominal/pelvic computed tomography showed fatty infiltration of the liver. The patient signed out against medical advice.

The proposed treatment was not medically necessary. 

This patient was admitted with alcohol withdrawal. The health plan denied the inpatient admission because the patient had not failed an observation level of care and the patient was not a danger to himself. The patient was not acutely intoxicated. The patient was hemodynamically stable and afebrile. He had mild tachycardia but no arrhythmia. He did not have persistent vomiting. He did not have a history of delirium tremens (DTs) or seizure. He had findings of liver failure. He did not have severe electrolyte abnormalities or renal failure. The patient was admitted with plan for work up liver disease. He signed out against medical advice (AMA) the next day. The patient did not have findings of severe alcohol withdrawal. He did not have symptoms that required an acute inpatient level of care and had not failed a lesser level of care. 
Services are generally considered medically necessary when they are:
- safe 
- effective
- generally accepted national standard of medical practice
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment options. The acute inpatient level of care was not medically necessary because it was not consistent with generally accepted national standards of medical practice for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Wegovy 2.4MG/0.75ML.
The insurer denied the request for Wegovy 2.4 milligrams (mg)/0.75 milliliters (ml).
The health plan's determination is upheld.

The patient is a female with a medical history of hypothyroidism, osteoporosis and obesity. She lost 28 pounds (lbs) on Wegovy. Her body mass index is 20.6 kilograms per meters squared (kg/m2). The request for the continuation of Wegovy is under review.

The requested health service/treatment of Wegovy 2.4 mg/0.75ml is not medically necessary for the patient. The patient's current body mass index is 20.6 kg/m2. She has a past medical history of hyperlipidemia. The patient's lipid profile was not provided. The patient does not have a documented body mass index of 30 kg/m2 or higher prior to treatment or a body mass index of 25 kg/m2 with a weight-related co-morbidity prior to treatment. 

The Wegovy prescribing information and the Endocrine Society guidelines on the management of obesity do not support the use of Wegovy in this clinical situation based on the provided documentation. Wegovy has risks, including nausea and vomiting. Therefore, the requested health service/treatment of Wegovy 2.4mg/0.75ml is not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II subdivision right occlusion
Treatment: Braces
The insurer denied: Braces
The denial is: Upheld

The patient is a male with a Class II subdivision right occlusion. He has 6 millimeter (mm) overbite and 3mm overjet. He has minor maxillary and minor mandibular crowing. He is treatment planned for orthodontics to correct his malocclusion. The subject under review is the medical necessity for braces.

There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions. He has minor crowding but no teeth are impacted. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are not contacting the palate in occlusion. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life.2
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute on Chronic Heart Failure. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay.
The determination is overturned. 

This is a female patient with a history of chronic systolic heart failure with severely reduced left ventricular ejection fraction (LVEF), hypertension, human immunodeficiency virus (HIV), active smoker, alcohol abuse, schizoaffective disorder, and homelessness, who presented to the emergency department (ED) with complaints of worsening shortness of breath, leg swelling and orthopnea after running out of her Lasix. On initial vital signs, the patient was hypertensive, with a blood pressure of 164/98. Lab results were notable for a high brain (or B-type) natriuretic peptide (BNP) of 3,711 picograms per milliliter (pg/ml). The patient was admitted to telemetry service for evaluation and treatment of acute on chronic heart failure and volume overload and acute coronary syndrome (ACS) rule out. She was treated with aggressive intravenous (IV) diuresis twice daily. While the patient's clinical status was improving, she remained volume overloaded. Despite not being medically stable for discharge, the patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay. 

Due to the patient's acute on chronic heart failure exacerbation with significant volume overload that persisted beyond an observation level of care time frame, inpatient level of care was medically necessary and appropriate in this case to achieve adequate decongestion and medical optimization prior to discharge. In addition, the combination of acute heart failure with high brain (or B-type) natriuretic peptide (BNP) level, complex comorbid conditions, and patient's homelessness is indicative of high risk for short-term adverse cardiovascular events including heart failure readmission and cardiovascular mortality. Given the patient's high level of medical complexity due to above factors along with a high BNP reflective for increased risk for readmission and mortality, inpatient level of care was medically necessary in the best interest for the safety of the patient supported by peer reviewed medical literature and expert consensus guidelines on acute heart failure management (1-4). 

The patient's acute heart failure presentation highlighted by significant volume overload, high BNP level, complex comorbid conditions, and limited self-care abilities due to homelessness is indicative of high risk for short-term adverse cardiovascular events including heart failure readmission and cardiovascular mortality strongly supporting an inpatient level of care in this case. Inpatient level of care was medically necessary and in the best interest for the safety of the patient to achieve adequate decongestion and medical optimization prior to discharge supported by peer reviewed medical literature and expert consensus guidelines on acute heart failure management (1-4).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The denial is overturned.

The patient is a young adult female with atopic dermatitis, affecting 30% (percent) BSA (body surface area). She has been treated with topical steroids, topical calcineurin inhibitors, phototherapy, and Dupixent. She responded well to Dupixent, but stopped due to pregnancy. Her provider is requesting restart of Dupixent. The health plan requires use of an oral immunosuppressant.

The requested Dupixent is medically necessary.

The patient has already responded well to Dupixent, and she is a female of childbearing potential. The oral immunosuppressants have a major risk of birth defects and are therefore not the most appropriate for this patient. Dupixent is a safer alternative for her, and she has already responded well. In the study cited below (Khamisy-Farah), Dupilumab use is evidenced to be safe during gestation. Further studies are needed, especially to better understand the mechanisms underlying the pharmacological actions and ADR (adverse drug reactions) of Dupilumab.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This adult female with a history of asthma presented with two episodes of syncope described as eyes rolling back and arm shaking followed by confusion. The patient states she saw lights and lost consciousness. The patient had a similar episode three weeks ago associated with a dental procedure. She complained of headache. The patient's vital signs were stable, and the patient was afebrile. There was no orthostasis. The patient's exam was remarkable for diffuse wheezing. Labs were unremarkable. Electrocardiogram (EKG) showed normal sinus rhythm and no ST (the area from the end of the QRS complex to the beginning of the T wave) changes. The patient's head computed tomography (CT) was with no acute disease. The patient was admitted for syncope. Plan of care included neuro-checks, magnetic resonance images (MRI), and electroencephalogram (EEG). On day # (number) 2, MRI of the brain and head showed no acute disease. The patient was cleared for discharge on the following day.

The proposed treatment was not medically necessary.

Most causes of syncope are benign. Studies have not proven that inpatient hospital admission of asymptomatic patients after syncope affects outcomes. There are no standard criteria for diagnosing undifferentiated syncope. Inpatient hospital admission should be reserved for patients identified to be at immediate risk, i.e. ("that is"), structural heart disease or history of ventricular arrhythmia. Outpatient management can be used for patients who are at low risk for a cardiac etiology. Evaluation showed the patient to be hemodynamically stable. The patient did not have fever or leukocytosis. EKG was unremarkable for arrhythmia and acute ischemia. There were no acute findings on head CT. The patient's labs were unremarkable. Based on the patient's severity of illness, acute inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Refractory Overactive Bladder (OAB)
Treatment: Nerve Treatment (percutaneous tibial nerve 
stimulation 
The insurer denied: Nerve Treatment (percutaneous tibial nerve 
stimulation 
The denial is overturned

The patient is an adult female. The request is for treatment with percutaneous tibial nerve stimulation (PTNS). She has tried behavioral modification and Myrbetriq without sufficient benefit.
The health plan denied coverage of the request. Per the decision letter, "This treatment is not approvable under the plan clinical criteria because it does not meet the standard of care for these problems." This denial is being appealed.

The requested percutaneous tibial nerve stimulation is medically necessary.

According to the AUA (American Urological Association) Guidelines for the Treatment of Overactive Bladder, "Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully selected patient population. Option (Evidence Strength Grade C)." 
Behavioral modification and pharmacologic therapies are the first- and second-line therapies, which the patient has failed.
Therefore, given the above, the request is in accordance with Generally Accepted Standards of Medical Practice. Additionally, the request is clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's conditions or its symptoms. The request is not mainly for the patient's convenience or that of the patient's doctor or other health care provider. The request is not more intensive than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's condition or symptoms. As such, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility.
Treatment: Fertility services (In-vitro fertilization ([IVF]).
The insurer denied fertility services (In-vitro fertilization ([IVF]).
The denial is upheld.

The patient is an adult female gravida one, para zero, abortion one (G1 P0 Ab1) - with a history of infertility. The patient underwent in-vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) was performed. The Health Plan has denied coverage due to lack of medical necessity.

The proposed treatment was not medically necessary.

The medical records and medical literature were thoroughly reviewed. There is no evidence of a specific diagnosis of the cause of the infertility. The American Society for Reproductive Medicine, in its Practice Committee Opinion, states: "Oocytes retrieved from older women have been theorized to have structural defects of the zona pellucida or cytoplasm that might reduce the fertilization rate with conventional insemination. In practice, oocyte fertilization rates in women older than 35 years using conventional insemination are similar to the fertilization rates of younger women. One retrospective study attempted to address this question, demonstrating similar fertilization rates, clinical pregnancy rates, and livebirth rates between women who had oocytes fertilized by conventional fertilization and those who had ICSI...ICSI for advanced maternal age does not improve live birth outcomes...In cases without male factor infertility or a history of prior fertilization failure, the routine use of ICSI for all oocytes is not supported by the available evidence". 

The American Society for Reproductive Medicine sets guidelines that are the standard of care for the treatment of infertility patients. In its Practice Committee Opinion, the American Society for Reproductive Medicine states that, unless there is a significantly abnormal semen analysis, the use of intracytoplasmic sperm injection (ICSI) when doing in-vitro fertilization does not result in better pregnancy rates. Therefore, the standard of care does not support in-vitro fertilization via intracytoplasmic sperm injection (ICSI), and it is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right renal calculus
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female, otherwise healthy except for thyroid troubles, on thyroid medication with right renal calculus scheduled for percutaneous nephrolithotomy (PCNL) for right renal stone. Percutaneous nephrolithotomy (PCNL) was attempted but was unable to access the stone. Ureteroscopy was performed but was also unable to access the stone. 
Nephrostomy tube and stent were placed, and the patient was admitted for monitoring. Estimated blood loss (EBL) was estimated at 100 milliliters (mL). The patient remained hemodynamically stable during the procedure and in the post anesthesia care unit (PACU). Acute inpatient admission was denied stating that there were no indications for acute inpatient admission and that the patient could have been managed at a lower level of care.

The proposed acute inpatient admission was not medically necessary.

The patient underwent and attempted percutaneous nephrolithotomy (PCNL) and ureteroscopy, both of which were unsuccessful for which a ureteral stent and nephrostomy tube were placed. The patient's estimated blood loss (EBL) was reported at 100 milliliters (mL). The patient was noted to be hemodynamically stable throughout the procedure, oxygenating well. She was initially managed in the post-anesthesia care unit (PACU) and met criteria for the next stage. The patient had no underlying medical conditions except for thyroid problems treated with thyroid medication. There was no documentation of prolonged hypotension, hypotension requiring treatment, excessive bleeding, decreased urine output or concerns. The medical records the following morning note an uneventful postoperative course, vital signs were stable, and the patient was afebrile and hemodynamically stable. A single hematocrit obtained decreased from a hemoglobin (HGB) of 12.7 and hematocrit (HCT) of 40.1 to a hemoglobin of 11.7 and hematocrit of 36.1, with no further lab testing obtained.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia type II.
Treatment: Lower Esophageal Myotomy Transoral (POEM).
The insurer denied: Lower Esophageal Myotomy Transoral (POEM).
The denial is: Upheld.

The patient is a female with Type II achalasia documented on esophageal manometry. Therefore, the attending gastroenterologist would like to do a peroral endoscopic myotomy (POEM) procedure to treat her achalasia. The subject under review is whether the requested procedure is likely to be of greater benefit to the patient than standard treatment for her condition.

Peroral endoscopic myotomy (POEM), a minimally invasive endoscopic technique, is one of the most recent advances in the treatment of achalasia. POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery. Several studies have established the short-term safety and efficacy of POEM. Serious adverse events are rare with POEM. They occur at a rate of less than (<) 0.1% with the most common serious event being perforation. Another, albeit less serious, complication following POEM is gastroesophageal reflux disease (GERD). In carefully selected patients, some studies have shown short-term postoperative clinical symptoms of GERD following POEM is 10.9%, comparable to that of laparoscopic cardiomyotomy. A study by Li and colleagues which followed over 500 patients who had the POEM procedure over 49 months showed that POEM is a highly safe and effective treatment for esophageal achalasia with favorable long-term outcomes. However, there are no data regarding the long-term efficacy of the procedure (beyond 5 or 10 years) as opposed to a conventional or laparoscopic Heller myotomy. According to current American Gastroenterological Association guidance, POEM is the preferred treatment option in type III achalasia when a longer myotomy is indicated. For other achalasia syndromes, POEM should be considered as a treatment option of comparable efficacy to laparoscopic Heller myotomy, albeit with no long-term outcomes data and minimal controlled outcomes data currently available. The POEM procedure to treat Type II achalasia in this patient is not likely to be of greater benefit than standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia type II.
Treatment: Lower Esophageal Myotomy Transoral (POEM).
The insurer denied: Lower Esophageal Myotomy Transoral (POEM).
The denial is: Overturned.

The patient is a female under evaluation and management for achalasia. The patient has been very symptomatic with dysphagia and vomiting after consuming solids and liquids. Upper endoscopy ruled out a structural lesion. High resolution manometry was classic for Type 2 achalasia.
The patient's provider has recommended the peroral endoscopic myotomy (POEM) procedure as definitive treatment. This request was denied by the plan which considers POEM to be not standard of care.
The subject under review is whether the proposed treatment is likely to be more beneficial for this patient's achalasia than any standard treatment. 
The proposed treatment is likely to be more beneficial for this patient's diagnosis. Peroral endoscopic myotomy (POEM) is the endoscopic equivalent of surgical myotomy and a newer technique for the management of achalasia. POEM has been endorsed as a primary treatment for type I and II achalasia by major society guidelines. [1] The efficacy and safety of POEM has been compared with that of laparoscopic Heller myotomy (LHM) [2]. In a randomized trial of 221 patients with idiopathic achalasia, POEM and LHM were equally successful in controlling symptoms at two years (83 versus 82%). Compared with LHM, POEM was associated with a lower rate of severe adverse events (2.7 versus 7.3%.). Furthermore, in a trial of 133 treatment-naive patients with achalasia, POEM resulted in a higher rate of treatment success than pneumatic dilation at two years (92 versus 54%, probability [p] less than [<] 0.001) [3]. POEM has established itself as the standard of care in Type 2 achalasia, the condition this patient has.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia type II.
Treatment: Lower Esophageal Myotomy Transoral (POEM).
The insurer denied: Lower Esophageal Myotomy Transoral (POEM).
The denial is: Overturned.

The patient is a female with achalasia requesting lower esophageal myotomy (POEM). Progress note describes planning POEM procedure. Medications include fluoxetine. Body mass index (BMI) is 23. Complete blood count (CBC) and metabolic panel were normal. The active problem list states there is difficulty swallowing. She has esophagus spasm, regurgitation, vomiting, and is not tolerating liquids and solids. Esophagogastroduodenoscopy (EGD) was unremarkable, distal esophagus biopsy with reflux, no Barrett's. Manometry showed elevated resting pressure, pan-pressurization, and Type 2 achalasia. A copy of the manometry study describes the elevated resting pressure, pan-pressurization, consistent with type 2 achalasia. All swallows had failed peristalsis. Impedance testing showed poor esophageal clearance consistent with achalasia.

Currently evidence shows that this procedure is considered safe, effective, as compared with standard means for treatment of achalasia. Reliable evidence such as published reports in the scientific literature shows that the consensus of opinion among experts is that the safety and effectiveness of POEM compared to standard means of treatment has been established. The literature supports the use of this procedure. The proposed procedure is likely to be of greater benefit to this patient than any standard treatment.