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

Diagnosis: Gynecomastia.
Treatment: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).
The insurer denied: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).
The denial is upheld.

This patient is a young adult male who presents with complaints of fullness behind both nipples since adolescence. The patient reports developing breast tissue just behind the nipples on both sides which caused projection. He has lost weight and has begun to work out in the gym frequently with a continued projection of the nipple. He reports that when he is cold and he has hardening of the nipples he has a normal profile. He would like to surgically correct the shape and fullness of his nipple. The patient denies taking prescription medications. He denies taking illicit drugs including marijuana. He denies testicular masses. Mastectomies and liposuction are planned.

The proposed treatment is not medically necessary.
The mastectomies are cosmetic. The patient has gynecomastia, but the records do not document any health or functional problems caused by the enlarged breasts. There is no documentation of an endocrine evaluation and exclusion of an endocrine cause. There is no documentation of a concern for a breast malignancy and there are no diagnostic studies provided. The records do not document a need for treatment with analgesics or problems with activities of daily living due to his enlarged breasts.  

Gynecomastia is a benign condition that does not cause health or functional problems.  According to a review article from the Mayo Clinic, "Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces the symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended...Patients with gynecomastia have a favorable prognosis. These patients present with 2 main concerns: ruling out breast cancer and cosmetic correction. The first concern is adequately addressed by following the appropriate diagnostic evaluation. Breast cancer is rare in males, representing less than 1% of all cases of breast cancer; only 1% of mammograms in men reveal breast cancer.  Therefore, the decision to treat and the choice of treatment should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction."  

The records do not provide any evidence of concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance, and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefits from the surgery, but his physiologic health will not be improved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Narcolepsy. 
Treatment: Xywav 0.5 gram (gm)/milliliter (ml) oral solution. 

The insurer denied coverage for Xywav 0.5 gram (gm)/milliliter (ml) oral solution. 
 
The denial is upheld. 

According to the medical records, this is a patient with narcolepsy and asthma. A Polysomnogram (PSG) was done, and the REM (rapid eye movement) latency was almost 159-minutes. The respiratory disturbance index was 1.5. Total sleep time was 405 minutes. A multiple sleep latency test (MSLT) showed a mean sleep latency of 10.40 minutes, and a REM sleep onset. She slept in all 5 naps, with REM latency occurring in nap 2 and 3. On an emergency room visit, she presented with shortness breath, irregular heartbeat, and dizziness. She reported starting Xyrem for narcolepsy. 

The health care plan acted reasonably, and with sound medical judgment in the best interest of the patient. The provided polysomnogram, followed by a next day multiple sleep latency test does not establish the diagnosis of narcolepsy.  The criteria on a MSLT is to have a mean sleep latency of less than 8 minute, and a REM sleep onset. In her case the mean sleep latency was more than 10 minutes. 

The provided MSLT, does not establish the diagnosis of narcolepsy. The diagnostic criteria for narcolepsy type 1 requires cataplexy and a mean sleep latency of less than 8 minutes, and 2 or more sleep onset REM cycles during MSLT, or sleep onset REM cycles within 15 minutes on the preceding nocturnal PSG that can replace 1 sleep onset REM from MSLT.  Another alternative is low cerebrospinal fluid hypocretin-1 which was not provided. 

INDICATIONS AND USAGE: "XYWAV is a central nervous system depressant indicated for the treatment of cataplexy or excessive daytime sleepiness (EDS) in patients 7 years of age and older with narcolepsy (1)". (Xywav Package Insert). 
"This systematic review provides supporting evidence for the accompanying clinical practice guideline on the treatment of central disorders of hypersomnolence in adults and children. The review focuses on prescription medications with U.S. Food & Drug Administration approval and nonpharmacologic interventions studied for the treatment of symptoms caused by central disorders of hypersomnolence." (Maski, K. et al. 2021). 

The insurer's denial of coverage for Xywav 0.5 gram (gm)/milliliter (ml) oral solution is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infection (leg)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female whose inpatient admission is under review. The patient noted onset of right lower extremity erythema and itchiness following an insect bite. She went to the ER (emergency room) and was prescribed Bactrim, which she took. The symptoms worsened over the next day and she presented to the ER (emergency room). She did not have fever. The patient was noted to be allergic to penicillin.

In the ER (emergency room), the patient's vital signs were as follows: T (temperature): 97.8, P (pulse): 79, RR (respiration rate): 17, BP (blood pressure): 109/72. On general examination, the patient was noted to be in no acute distress. Examination of the patient's chest, CVS (cardiovascular system), and abdomen were normal. Examination of the patient's RLE (right lower extremity) revealed right leg erythema and edema. Linear erythematous band extending proximally along medial aspect of thigh was noted.

The patient's labs were as follows:
WBC (white blood count): 8.1 (repeat 13.7)
Hg (hemoglobin): 13.6
Hct (hematocrit): 40.0
Plt (platelets): 266
Na (sodium): 138
K (potassium): 4.8
Cl (chloride): 109
CO2 (carbon dioxide): 23
BUN (blood urea nitrogen): 16.5
Cr (creatinine): 0.83

Duplex of the LE (lower extremity) revealed no DVT (deep venous thrombosis).

In the ER (emergency room), the patient was thought to have RLE (right lower extremity) cellulitis and thrombophlebitis. She was started on IV (intravenous) clindamycin, after which she improved. She was discharge on PO (oral) clindamycin and Bactrim.

Yes, the Inpatient admission was medically necessary.
The patient meets criteria for inpatient admission and IV (intravenous) treatment according to the Infectious Disease Society of America (IDSA), because she had systemic signs of infection (leucocytosis). In addition, standard of care necessitated her admission, as there was a clinical suspicion of a deeper and more serious infection (thrombophlebitis).

Therefore, given the above, the Inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. Failure to admit such a patient could result in loss of function, septic shock, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems - Malocclusion. 
Treatment: Dental or Orthodontic Treatment. 

The insurer denied: D8080 comprehensive orthodontic treatment of the adolescent dentition. The denial is overturned. 

The patient in question is a female presenting with a skeletal Class I malocclusion and minor crowding. She has an anterior open bite. She is treatment planned for orthodontic treatment address the crowding and open bite, but the treatment which was denied by the health plan due to lack of medical necessity. 

The health plan's determination is overturned. 

The comprehensive orthodontic treatment of the adolescent dentition was medically necessary for this patient. 

Anterior open bite patients are among the most difficult patients to treat. (1) One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthodontic treatment is medically necessary for this patient due to the side effects, and the fact that this is not something that will self-correct without orthodontic intervention. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. (3)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse, Bipolar Disorder.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who presented to facility for treatment of alcohol dependence.  His primary diagnoses were alcohol dependence with withdrawal, anxiety disorder not otherwise specified (NOS), cocaine dependence uncomplicated, cannabis abuse uncomplicated and bipolar disorder, depressed, moderate. The initial request for hospitalization was denied as it was found to be not medically necessary. The patient was noted to not be acutely ill from alcohol related issues and did not require medical management as the patient did not have severe withdrawal or risk of severe withdrawal symptoms.

The patient reported being referred by another facility. On admission, the patient was noted for being homeless for approximately five years. He reported experiencing anxiety and living with short-term memory loss due to brain injury. He denied any suicidal or homicidal ideation or intent. He requested rehabilitation. The patient acknowledged drinking up to three pints of vodka per day. His first use was approximately 15 years prior and last use was on date of admission. Toxicology screen was positive for cannabis, cocaine and benzodiazepines. The patient scored seven on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) on admission. Highest Shiva score during admission was an eight on day two. The patient's vital signs were stable on admission. The patient reported a history of blackouts with last blackout prior to admission. He reports no prior treatment history for addictions and at least ten past relapses. Longest period of sobriety was approximately 17 months. He currently resides in a homeless shelter. He does report family is supportive of recovery. There was no trauma history noted. The patient reports a history of depression, anxiety and attention deficit hyperactivity disorder (ADHD)  He is not on any psychiatric medications. The patient does not report a history of complicated withdrawals or withdrawal seizures.

No, the proposed treatment was not medically necessary.
The patient did present with a history of substance abuse, specifically alcohol, cocaine and cannabis.  However, the patient did not present with severe acute alcohol withdrawal. On admission, his Clinical Institute Withdrawal Assessment for Alcohol score was a seven, indicating mild withdrawal. His vital signs were stable. He had no history of complicated withdrawal or of withdrawal seizures. He did not present as at risk for severe withdrawal symptoms.  He did not have acute medical or psychiatric comorbidities requiring inpatient admission. Based on the documentation submit, the patient's alcohol related issues could have been treated at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Based on patient's presentation, and review of the medical records, patient did not meet necessity for acute inpatient alcohol detox.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This patient with a history of hypertension and diabetes mellitus presented to the hospital for cardiac catheterization following a positive stress test.  Prior to stress testing, the patient reported symptoms of worsening dyspnea on exertion.  Cardiac catheterization revealed multivessel coronary artery disease that included 60% (percent) proximal and mid left anterior descending artery occlusion, 60% proximal first obtuse marginal coronary artery, 80% proximal second obtuse marginal coronary artery and distal disease of the right coronary artery.   Attempted percutaneous intervention to the second obtuse marginal coronary artery was not successful.  The patient was admitted to telemetry for overnight observation.  Left ventricular (LV) ejection fraction was 50%.  No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization.  He underwent an unsuccessful and uncomplicated procedure and was discharged the following day.  Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. The patient could have been managed at a lower level of care.

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: Low Back Pain
Treatment: Intracept Procedure (64628, 64629)
The insurer denied: Intracept Procedure (64628, 64629)
The denial is upheld.

The patient is an adult female with low back and right knee pain. She has tried physical therapy, NSAIDs (nonsteroidal anti-inflammatory drugs), gabapentin, and opioids. MRI (magnetic resonance imaging) of the lumbar(L) spine shows multilevel disc herniations most notable at L4-5 and multilevel facet arthropathy. The request for Intracept at L4-S (sacral)1 was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The requested Intracept procedure is not medically necessary.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such the requested Intracept procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung disease (difficulty breathing)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.  
The denial is upheld.

The proposed inpatient hospital admission was not medically necessary.

This patient is a female with severe chronic obstructive pulmonary disease (COPD) on three liters home oxygen with worsening shortness of breath / dyspnea on exertion (SOB/DOE) due to chronic obstructive pulmonary disease (COPD) exacerbation. Despite emergency room treatment, the patient continued to have worsening shortness of breath / dyspnea on exertion (SOB/DOE). The patient was admitted to acute in-hospital level of care for three days. The patient was treated with intravenous steroids, nebulization and antibiotics. 
The acute hospitalization was denied due to lack of medical necessity. This denial is being appealed.
The patient was admitted to the acute in-hospital level of care for chronic obstructive pulmonary disease (COPD) exacerbation. The patient was started on intravenous steroids, nebulization, and intravenous antibiotics. The patient's condition slowly improved with the treatment. The patient was at baseline within 48 hours of the treatment.
Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 to 48 hours, as is what happened with the patient. The patient's treatment course would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care.
The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Altered levels of salt within the body.
Treatment: Full Hospital Admission
The health plan denied the requested full hospital admission as not medically necessary. 
The health plan's determination is overturned.

The patient is a male. He was admitted to the hospital. He has a past medical history of Crohn's disease and chronic kidney disease.
The patient presented with hypokalemia and had weakness. He reported having 5-6 bowel movements a day. His potassium level was 2.2. He was going to be started on Infliximab soon prior to this admission. Vital signs showed a blood pressure of 111/88 millimeters of mercury (mmHg), a pulse of 70 beats per minute (bpm), a respiratory rate of 18/minute, a temperature of 98.4 F (Fahrenheit) and an oxygen saturation of 100% on room air. Labs showed a sodium of 137, a potassium of 2.0, a chloride of 105, a bicarbonate of 15, a blood urea nitrogen (BUN) of 20, a creatinine of 2.2, a glucose of 85, a white blood cell count of 5 and a hemoglobin of 11.3. He was started on intravenous (IV) fluids, magnesium, potassium and was admitted for further management and evaluation.

At issue is the medical necessity for a full hospital admission.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The requested health service/treatment of a full hospital admission was medically necessary for this patient.
The patient has history of Crohn's disease. He presented with severe hypokalemia and weakness. He was also noted to have acute kidney injury and a low magnesium (0.9). He was given aggressive electrolyte replacement and intravenous fluids with improvement.
During the course of the hospital stay, the patient was given Prednisone for the flare. Labs improved; his potassium was 4.3 on last check prior to discharge. His diarrhea improved. The creatinine also came down to 1.57. 
The severity of the manifestations of hypokalemia tends to be proportionate to the degree and duration of the reduction in serum potassium. Symptoms generally do not become manifest until the serum potassium is below 3.0 mEq/L (milliequivalents/liter). In this case it was 2.0. Muscle weakness usually does not occur at serum potassium concentrations above 2.5 mEq/L if the hypokalemia develops slowly. However, significant muscle weakness can occur at serum potassium concentrations below 2.5 mEq/L. [1]
In addition to causing muscle weakness, severe potassium depletion (serum potassium less than 2.5 mEq/L) can lead to muscle cramps, rhabdomyolysis, and myoglobinuria. [2] A variety of arrhythmias may be seen in patients with hypokalemia. These include premature atrial complex and premature ventricular beats, sinus bradycardia, paroxysmal atrial or junctional tachycardia, atrioventricular block, and ventricular tachycardia or fibrillation. Hypokalemia produces characteristic changes on the electrocardiogram, although they are not seen in all patients. [3]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic anemia
Treatment: Inpatient Hospital Admission
The health plan denied the inpatient hospital admission as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a history of gastroesophageal reflux disease (GERD), chronic anemia, arthritis, and osteoporosis. She was referred to the emergency room (ER) from the rheumatologist with a critically low hemoglobin (Hb) of 5.2 grams per deciliter (g/dl). The patient was complaining of dyspnea and progressive fatigue. She also noted having blood-tinged stools that were thought to be from hemorrhoids. In the ER, the patient was hemodynamically stable except for a slightly soft blood pressure (BP) of 94/66 millimeters of mercury (mmHg). The patient had a Hb of 5.2, a hematocrit (Hct) of 19, a white blood count (WBC) of 4, a blood urea nitrogen (BUN) of 28, and a chloride (Cl) of 109. The patient was given intravenous (IV) hydration and 2 units of packed red blood cells (PRBC). She was started on IV proton pump inhibitors (PPI). A gastrointestinal (GI) specialist was consulted and recommended an esophagogastroduodenoscopy (EGD) and colonoscopy. An endoscopy showed hemorrhoids, several non-bleeding Angioectasia, and inflammation in the gastric antrum. The patient was initially in a nothing by mouth (NPO) status, but her diet was slowly advanced. The patient's Hb remained stable. She was subsequently discharged home. An inpatient hospital admission was requested.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient hospital admission was medically necessary for this patient.

The patient was referred to the ER from the rheumatologist with a critically low Hb of 5.2 g/dl. The patient had severe life-threatening anemia and was symptomatic with dyspnea and worsening fatigue. She was confirmed to have Hb of 5.2. A GI specialist was consulted, and an endoscopy was recommended. The EGD showed several telangiectasia and gastric inflammation. The patient was also found to have hemorrhoids. The patient had severe life-threatening anemia as defined by the Hb of less than (<) 6.5. Urgent intervention and close monitoring are recommended in this situation. [1] The patient had an elevated risk for recurrent bleeding and arteriovenous malformations (AVM)/telangiectasia and warranted close observation and monitoring in the inpatient setting.

The patient was suitable for an inpatient level of care due to severe life-threatening symptomatic anemia and an enhanced risk of recurrent bleeding. 

Therefore, the requested health service/treatment of inpatient hospital admission was medically necessary.