Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cancer, cerebellar metastases
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is modified, two inpatient days are approved.

This is a patient with a history of breast cancer with metastases, deep vein thrombosis (DVT), diabetes, COVID (Coronavirus), rheumatoid arthritis, steroid myopathy, and urinary incontinence for 4 years. She had a resection of cerebellar metastasis 4 years ago. The patient presented to the hospital from a skilled nursing facility (SNF) with complaints of left facial numbness, diplopia, and tongue numbness. Magnetic resonance imaging (MRI) of the brain showed cerebellar metastases. During the admission, the patient was seen by Breast Medicine, Neurology, and Radiation Oncology consulted over the case. During the admission, the patient was treated with pantoprazole, potassium chloride, simethicone, pregabalin, memantine, apixaban, dexamethasone, atorvastatin, lisinopril, and sliding scale insulin. 

The clinical presentation justified the admission while new metastases, leptomeningeal disease, or stroke were being investigated or ruled out. Her neurological symptoms have been present since external beam radiation therapy (EBRT); the only new symptom was facial numbness, which resolved.

As such, the first and second day of admission is appropriate. Ongoing admission was not medically necessary.      

"Brain metastasis, which commonly arises in patients with lung cancer, breast cancer and melanoma, is associated with poor survival outcomes and poses distinct clinical challenges. The brain microenvironment, with its unique cell types, anatomical structures, metabolic constraints and immune environment, differs drastically from microenvironments of extracranial lesions, imposing a distinct and profound selective pressure on tumour cells that, in turn, shapes the metastatic process and therapeutic responses." (Boire A., et al, 2020)

"Acute stroke is a leading cause of morbidity and mortality in the United States. Acute ischemic strokes have been classified according to The Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system, and this system aids in proper management. Nearly every patient who presents to a hospital with acute stroke symptoms has some form of emergent imaging. As such, imaging plays an important role in early diagnosis and management." (Knight-Greenfield A., et al, 2019)

"Metastasis, involving the spread of systemic cancer to the brain, results in neurologic disability and death. Current treatments are largely palliative in nature; improved therapeutic approaches represent an unmet clinical need." (Valiente M, et al, 2018)

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for the full hospital admission is modified. The admission for two days is medically necessary. The continued admission beyond two days is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: obstructive sleep apnea (OSA).
treatment: Hypoglossal Nerve Stimulator .
The insurer denied Hypoglossal Nerve Stimulator. 
The health plan's determination is overturned.

The patient is a male with a history of obstructive sleep apnea. He had a prior apnea hypopnea index of 83.10. His body mass index (BMI) was 27.80. A prior drug induced sleep study did show an absence of a complete concentric collapse at the soft palate. In addition, the patient had documentation of failure to use continuous positive airway pressure (CPAP) - unable to keep the mask on through the night. On exam, the patient had a Maliampati grade 4 oral airway. Past medical history was significant for Trisomy 21. Based on the history and exam, the provider recommended hypoglossal stimulation. 

The hypoglossal stimulation is medically necessary to treat the obstructive sleep apnea (OSA) in this patient.
The patient has significant sleep apnea (severe) and has failed appropriate measures for OSA (CPAP). Based on the patient's history, it is likely that the patient's severe OSA will continue. The Food and Drug Administration (FDA) has approved hypoglossal stimulation for adolescents between 18 and 21 years of age. If the patient continues to have untreated OSA, he is at significant risk for systemic co-morbidities including lung disease and sudden cardiac death. The severity of the apnea hypopnea index (AHI) should not be a limiting factor for this patient. Current literature does show that patients with a more significant AHI are appropriate candidates for hypoglossal stimulation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rash
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld. 

The patient is a male who was asked to return to the emergency room for a positive blood culture on a specimen obtained the previous day for chest pain. The day before, he had a chest computed tomography (CT) angiogram that revealed small lung nodules of uncertain etiology; physical exam had a rash concerning for lupus. There was a positive family history for lupus. The blood culture was called to the emergency department (ED) as showing gram positive cocci in clusters in one bottle at 25 hours. The other bottle was negative at 48 hours. He was afebrile, felt fine, without chills, nausea, vomiting, headache, diarrhea, constipation, abdominal pain, or ill contacts. Other than the rash, his physical exam was normal and he appeared well. 

The inpatient hospital admission was not medically necessary.

The patient presented with a constellation of chronic symptoms--rash, pain--and a broad workup was initiated in the emergency department and plans for specialist follow up had been arranged. Included in this broad workup was a blood culture. At 25 hours, one of the two bottles was positive for gram positive cocci in clusters; the other bottle was negative at that time. Because of the possible bacteremia, he was recalled to the emergency department.

The gram stain morphology (clusters), the normal C-reactive protein (CRP), the normal pro-calcitonin, the absence of fever, the well appearance, the normal vital signs, the clinical improvement without any antibiotics, and the absence of growth in the second of two blood culture bottles all provided strong independent evidence that he did not have bacteremia or sepsis requiring hospitalization or treatment.

Typically, if one were concerned about bacteremia (as opposed to contamination) and/or sepsis, one would start broad spectrum parenteral antibiotics, including vancomycin or another anti-staph (methicillin-sensitive and methicillin-resistant) antibiotic that one would use if there was a concern for a pathogenic gram positive coccus that grows in clusters (e.g., staph aureus).

No parenteral antibiotics were started in this case. They did use the time in the hospital to expedite the subspecialist workup of the nodes and rash, but expediting these evaluations were a convenience, not a medical necessity based on his clinical presentation. The acute inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder - odontoma
Treatment: D8080 Braces; D8670 Monthly visits
The insurer denied the D8080 Braces; D8670 Monthly visits
The determination is overturned.

This is a female patient. Tooth 6 is being blocked from eruption by an odontoma. She presented with a skeletal Class I malocclusion and crowding. She is treatment planned orthodontic treatment to address tooth 6 and the odontoma but treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces and monthly visits.

The longer an odontoma is left in place the greater the risk of damage to the adjacent teeth. (1) If left untreated the damage that will likely occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. Studies show that odontomas can lead to damage to the adjacent permanent teeth that could lead to them needing extraction. If the permanent tooth is not damaged by the odontoma or its removal, the potential for that tooth to require combined orthodontic/surgical treatment to assist its eruption is very high. (2) Therefore, it is reasonable and customary to apply orthodontic traction to the blocked-out tooth at the time of the surgical removal of the odontoma. 

For these reasons, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: syncope
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is upheld. 

This case involves a man with multiple medical problems who presented to the hospital with near syncope. He described lightheadedness and dizziness but did not lose consciousness. He was assessed and found to be hypotensive, with systolic blood pressure in the 80's. He was seen by his primary care physician, who sent him to the emergency department. He denies any chest pain or shortness of breath. Orthostatic in the emergency department (ED) were significantly positive, and the patient was bolused with 2 L (liters) of normal saline. The patient had recently completed therapy for osteomyelitis of the right calcaneus. On exam, the right lower extremity was bandaged without purulence or the wound's erythema.
The patient was admitted to the hospital with orthostatic hypotension causing near syncope. 

The inpatient hospital admission was not medically necessary.
Evaluation and treatment of orthostatic hypotension causing near syncope does not require inpatient admission. Orthostasis is typically treated with observation, with IV fluid resuscitation and serial orthostatic blood pressure rechecks until normalization occurs. This patient responded appropriately to IV fluid resuscitation and was no longer symptomatic with orthostatic hypotension within 24 hours of presentation. Therefore, an Inpatient admission is not indicated.
Near syncope caused by orthostatic hypotension does not necessitate inpatient admission. The patient was not very responsive to IV fluid resuscitation, completely asymptomatic within 24 hours. As documented by the medical team, he walked out of the hospital without any symptoms. There was no documentation of cardiac arrhythmias to raise any concerns. The symptoms were quite obvious, relating to a hypovolemic state that responded very well to the infusion of crystalloid solution. A lower level of care is appropriate for this presentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; headache
treatment; inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns of severe headache, nausea, and myalgias. Pertinent history included a seizure disorder. Initial vital signs revealed a temperature of 102.7oF, heart rate (HR) 119, blood pressure (BP) 111/81, and respiratory rate (RR) 18. Initial examination documented the patient as alert and oriented x 1 without focal neurological deficits. Equivocal Brudzinski / Kernig sign. An electrocardiogram (EKG) revealed sinus tachycardia. Chest radiograph was unremarkable. A computed tomography (CT) head was unremarkable. Lumbar puncture was performed and fluid analysis revealed an elevated protein level. Empiric vancomycin, cefepime, and acyclovir were administered. Following the lumbar puncture, the presenting symptoms had largely resolved. The patient was placed in the hospital thereafter with an impression of altered mental status secondary to meningitis / meningoencephalitis, seizure disorder and polycythemia. 

The patient had a history of a seizure disorder who presented with confusion, headache, and fever. Initial evaluation revealed a fever of 102.7oF. tachycardia, and disorientation. A lumbar puncture was performed in the emergency department which revealed an elevated protein. Following the lumbar puncture, significant improvement in mentation and symptoms were achieved. Treatment thereafter included broad spectrum anti-infective agents. Infectious disease consulted and had an impression of enteroviral meningitis. Recommendations were to discontinue all antimicrobial agents. Following observation care, mentation was at baseline and symptoms were significantly improved or resolved. Supportive care was pursued. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have bacterial meningitis, encephalitis, hemodynamic instability, severe or persistent altered mental status, severe neurologic findings, severe or persistent vomiting, severe or persistent dehydration, severe pain, cerebral bleeding, or increased intracranial pressure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioma
Treatment: Proton Beam Therapy
The insurer denied the Proton Beam Therapy.
The determination is overturned.


This is a female patient with a midline glioma status/post (s/p) subtotal resection. She has been recommended to proceed with a course of postoperative external beam radiotherapy. The request is for proton beam radiation therapy. At issue is whether the proton beam radiation therapy is medically necessary.


Yes, proton beam radiation is medically necessary for this patient. The treating provider supplied a proton versus photon plan comparison which revealed that photon-based intensity modulated radiation therapy (IMRT) is unable to provide adequate safety/precision with regard to normal tissue exposure. The photon plan would result in a significantly higher risk for pituitary dysfunction, bilateral cataracts, ipsilateral deafness, and neurocognitive deterioration. Owing to its improved ability to minimize exposure to these normal tissues, the proton radiation plan would be expected to significantly minimize these risks for toxicity as well as the risk for radiation induced secondary malignancy. Proton radiation for management of the patient's central nervous system (CNS) malignancy is supported by the American Society for Radiation Oncology (ASTRO) Model Policy as well as numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature. Proton radiation is frequently employed for similar patients nationwide who cannot be treated safely/effectively with the use of photon-based IMRT.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right below the knee amputation.
Treatment: Durable Medical Equipment (Right Below the knee prosthesis).
The insurer denied: Durable Medical Equipment (Right Below the knee prosthesis).
The denial is: Upheld.

The patient is a male with right below the knee amputation. He had a gunshot wound to his right ankle. He subsequently developed osteomyelitis and underwent a right below the knee amputation. At issue is the medical necessity of durable medical equipment: right below the knee prosthesis.

The health plan's determination is upheld.

The requested health Durable medical equipment (right below the knee prothesis) is not medically necessary for this patient.
The patient had a gunshot wound to his right ankle. He subsequently developed osteomyelitis and underwent a right below the knee amputation. The patient's provider stated that the patient no longer complained of a right below knee amputation (BKA) rash. He saw a dermatologist who treated him for the rash and it resolved. He was wearing a loose right lower extremity prosthesis with a worn sock. In a subsequent note, the provider stated that the patient complained of bilateral knee pain. He had recently cut his wrist and was treated at Urgent Care. On exam, he had a 5 centimeter (cm) laceration over the left wrist and sutures were intact. He had a right BKA with a sock that was worn in several places. The bilateral knees were tender anteromedially. He walked with the left leg externally rotated. The diagnoses were bilateral knee pain and left wrist laceration.
Subsequently, the provider note stated that the patient's sock was worn and torn. The prosthesis was loose. He complained of pain in the stump as well as an ill-fitting device. He also complained of left knee pain and falling a lot. The medical records provided do not document a detailed history of his bilateral lower extremity symptoms, pertinent physical examination findings including right serial residual limb measurements such as length and circumference and skin exam, detailed examination of the symptomatic (painful) left knee, medication records, progress reports, imaging studies of the bilateral knees, or laboratory tests. There is no documentation of the residual limb change in size and shape throughout the day, including measurements from the last prosthesis. There is no documentation of the functional level (K level). There is no detailed description of the prosthesis, age, or components. Further, his diagnoses of bilateral knee pain are nonspecific and further workup such as laboratory testing and imaging studies would be prudent to determine the etiology of the bilateral knee pain prior to obtaining a prosthesis. Therefore, the medical necessity for the requested device is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: type I diabetes

Treatment: rehabilitation treatment

The insurer denied coverage for rehabilitation treatment

The denial is overturned

 
The patient has type I diabetes with poor control and multiple diabetic ketoacidosis (DKA) intensified and despite frequent visits both outpatient and inpatient, the patient has failed all outpatient treatment. 

The program to which the patient has been referred improves decision-making regarding diabetes, lifestyle choices and improvements in hemoglobin A1C. There are studies showing that such programs improve patient compliance, diabetes control as well as increase healthcare savings. 

The Intensive inpatient treatment program is expected to be beneficial for the patient and is therefore medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for rehabilitation treatment is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hepatocellular carcinoma
Treatment: Y90 radioembolization 
The insurer denied Y90 radioembolization.
The determination is upheld.

This is a patient with hepatocellular carcinoma (HCC) who had bland embolization which reduced the tumor size from 2.8 centimeters (cm) to 1.9 cm. A recent magnetic resonance imaging (MRI) exam shows an increase in size of lesion, but no extrahepatic disease. The provider wishes to perform Yttrium (Y)-90 radioembolization. At issue is whether the Y-90 radioembolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Y-90 radioembolization is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Medical records indicate the patient is a candidate for resection or liver transplant. Y90 radioembolization has not been proven to be superior to standard medical treatments such as resection, transplant, or even radiofrequency ablation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hepatocellular carcinoma
Treatment: Y90 radioembolization 
The insurer denied Y90 radioembolization.
The determination is overturned.

This is a patient with a history of unresectable hepatocellular carcinoma in segment eight (VIII) of her liver status/post (s/p) prior bland embolization. She has radiographic evidence of progression. The request is for of Yttrium (Y) 90 radioembolization. At issue is whether the Y90 radioembolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed Y-90 radioembolization is likely to be more beneficial than any standard treatment for the insured's life-threatening disease. Y-90 embolization is widely utilized and supported by expert consensus national guidelines for management of unresectable hepatocellular carcinoma as it is proven to maximize the patient's chances for long term overall survival by preventing tumor progression and death from hepatic failure. Radioembolization is supported by numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature. Radioembolization allows for optimal target coverage while maximally sparing the patient's surrounding normal liver to limit the risk for radiation induced hepatic injury. The National Comprehensive Cancer Network (NCCN) guideline supports the use of radioembolization in the patient's situation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hepatocellular carcinoma
Treatment: Y90 radioembolization 
The insurer denied Y90 radioembolization.
The determination is overturned.

The patient has a history of hepatocellular carcinoma (HCC) in segment eight (VIII) now enlarging. She needs Yttrium (Y)-90 planning and also treatment arteriogram procedures performed. There is a request for treatment authorization for the Y-90 therapy.

The patient's past medical history was reviewed. She had an unsuccessful bland embolization procedure recently. She had an infection recently. Pertinent past medical records note good performance status. Her past surgery history was reviewed. Medications, lab work, and abnormal chemistries were noted. The current treatment plan was to be scheduled in that Y-90 infusion and a planning arteriogram need to be performed.

At issue is whether Y90 radioembolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service/treatment or procedure of Y-90 radioembolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Palliative loco-regional therapy is well tolerated and quite efficacious for this patient in this situation. Y-90 is proven effective but is limited to centers with capability. This is another procedure that gives a good chance for health improvement. The disease is liver dominant. The patient has good performance status. No extrahepatic disease is known.
Other therapies do not have the potential to eliminate the entire segment, so-called radiation segmentectomy using Y-90.

This patient meets accepted criteria in the literature. All tumors regardless of size may be amenable to Y-90. Locoregional liver therapy is appropriate for patients who are not surgical candidates or do not want surgery with HCC.