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

Diagnosis: Dental Disorder
Treatment: Crown Tooth # 10
The insurer denied the Crown Tooth # 10
The determination is upheld.

The patient presented with a root canal treated tooth number (#)10. A crown is being requested at this time. The medical necessity of the crown is under review.

According to the provided radiographs, tooth #10 is root canal treated and has a post. The tooth has adequate tooth structure and the only filling is located where the access hole is. Root canal treated teeth do not automatically need crowns unless there is visible evidence of large decay, fracture, or minimal tooth structure remaining. In this case, because the tooth has adequate tooth structure remaining, the tooth is strong enough to withstand occlusal forces without the protection of a crown.
Therefore, the request for a crown on tooth #10 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laceration Without Foreign Body, Left Foot (S91.312D)

Treatment: emergency room visit (99283)

The insurer denied coverage for emergency room visit (99283)

The denial is upheld

This case involves a female who presented to the emergency department for suture removal.  The documentation provided from the emergency department indicated the patient was seen to remove sutures which were placed on a few weeks ago.  She indicated she has been washing the wound twice a day and applying ointment.  She reported no issues with the wound.  She denied any bleeding or drainage.  The submitted documentation indicated on physical examination the patient was well-appearing.  She had a well-healing wound to the dorsum of the left foot.  Sutures were in place and there was no dehiscence, erythema, or drainage.  The wound appeared clean dry and intact, and the patient had full active and passive range of motion.  The patient did undergo suture removal and 7 sutures were successfully removed without complication.

This matter involves a denial for emergency services. Section 4900(c) of the New York State Insurance Law describes an emergency condition as "a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

1. Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition,
placing the health of such person or others in serious jeopardy;
2. Serious impairment to such person's bodily functions;
3. Serious dysfunction of any bodily organ or part of such person; or
4. Serious disfigurement of such person."

The visit involved removal of sutures, which was not sudden in onset or involve risk of death, serious impairment or disfiguration to any body part.  Patient's appeal states she was told to go to the emergency room because of severe bleeding from the wound, but this is inconsistent with the medical record from the day which states the patient reported no complications from the wound, and was clean, dry, intact when examined by the provider.  For these reasons suture removal could have been addressed in the office rather than the emergency department.

The health plan acted reasonably with sound medical judgment.

The insurer's denial of coverage for the emergency room visit (99283) is upheld. The prudent layperson standard was not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: polyhydramnios and preterm contractions	

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of polyhydraminios with a reduction of amniotic fluid done twice. After the second reduction, she had contractions and was then admitted to the hospital for polyhydramnios and preterm contractions.  She was given a betamethasone injection and intravenous (IV) iron sucrose.  Her contractions stopped and she was discharged with instructions for outpatient follow up.

Preterm labor is an indication for admission and tocolysis.  Preterm labor is defined as uterine contractions with cervical changes.  During this admission, there was no documentation of any cervical changes.  So the patient was not in preterm labor.
Ideally, this patient would have been observed in labor and delivery, received intravenous (IV) fluid and then would have been reevaluated a few hours later.  If upon reevaluation, no cervical changes occurred then she would be sent home.  If cervical changes did occur then she would be admitted for tocolysis and further management.
Please note that neither the patient nor the fetus were in any jeopardy.  There was no bleeding, and vital signs were stable.  Fetal heart rate was reassuring.  There was no evidence of ruptured membranes.
The management that this patient received during her admission could have been easily done in a less acute setting: Once the provider ascertained that there was no evidence of preterm labor, (no change in cervical status after few hours of observation) the patient could have been sent home after being hydrated.
 Based on the above, admission to the hospital was not medically necessary. This is in accordance with standard of care and Milliman guidelines.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Epigastric pain; Chest pain. 
Treatment: Inpatient hospital stay. 

The insurer denied coverage for inpatient hospital stay. 

The denial is upheld. 

This male patient presented to the hospital with epigastric and chest pains.  He had chronic kidney disease.  He was afebrile and the vital signs were stable.  The abdominal exam was benign.  The electrocardiogram (EKG) did not have ischemic changes.  He was treated with Protonix for gastroesophageal reflux disease (GERD).  The troponins were negative. 

MCG clinical indications for admission for chest pain (M-89) include hemodynamic instability, respiratory distress, aortic dissection, and angina or myocardial infarction.  The patient did not have these conditions. 

MCG clinical indications for admission for esophageal disease (M-550) include suspected perforation, complete esophageal obstruction, mediastinitis, severe vomiting, severe electrolyte abnormalities, an inability to maintain oral hydration after observation care, and the need for inpatient surgery.  The patient did not have these conditions. 

This patient had symptoms that were likely related to GERD.  He did not have an acute cardiac event.  He could have received proton pump inhibitor (PPI) therapy as an outpatient once acute coronary syndrome (ACS) was ruled out.  His blood pressure was amenable to outpatient treatment.  He did not meet MCG criteria for admission for either chest pain or esophageal disease.  

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  An inpatient admission was not medically necessary.  

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

Diagnosis: Immunologic Disorders/Arthritis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription medication, Rasuvo. 
The health plan's determination is upheld.

The patient is a female with psoriasis and severe rheumatoid arthritis (RA). She also has fibromyalgia. The rheumatoid factor (RF) and cyclic citrullinated peptide (CCP) are negative. The C-reactive protein (CRP) is within normal limits and the erythrocyte sedimentation rate (ESR) is minimally elevated at 24. The issue in this case is that Rasuvo is being denied by the health plan. Formulary alternatives are Methotrexate (MTX) intramuscular (IM), Arava, Plaquenil and SSz (Sulfasalazine). The provider states the patient is unable to use her hands due to synovitis and is not able to tolerate oral alternatives due to gastroesophageal reflux disease (GERD). The patient has been on oral MTX in the past but is unable to tolerate due to GERD.
At issue is the medical necessity of the requested prescription drug, Rasuvo.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of Rasuvo 15 MG/0.3ML SC SOAJ is not medically necessary for this patient at this time. GERD is not a contraindication to trying Plaquenil, Arava and Sulfasalazine and these are all reasonable options to treat RA. In terms of IM MTX (generic), I would see if there is someone who can help her draw it up and prepare it before discounting this option. There is no reason she cannot try formulary alternatives. She takes many other oral medications (e.g., Tizanidine, Fluoxetine, Amitriptyline).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dermatofibrosarcoma protuberans.
Treatment: Proton Beam Therapy.
The insurer denied Proton Beam Therapy.
The determination is upheld.

The patient has a prior history of (h/o) trauma to the scalp who developed a sarcoma of skin. The patient underwent surgery in Pakistan. The patient was evaluated for adjuvant radiation therapy (RT) for dermatofibrosarcoma protuberans. Proton beam therapy is under review for medical necessity.
The requested health service/treatment of Proton beam radiation therapy is not medically necessary for this patient.
Proton beam therapy is a type of particulate radiation therapy that differs from conventional electromagnetic and/or photon radiation therapy. The use of protons is produced by an accelerator (cyclotron, synchrotron, synchrocyclotron, or linear). This type of radiation is proposed to allow for minimal scattering as particulate beams pass through tissue disposing ionizing energy at precise depths (i.e., the Bragg peak) to minimize tissue damage in the surrounding area. Based on a review of the peer reviewed medical literature which includes meta-analysis, systematic reviews, small retrospective and prospective studies and case series the evidence is insufficient for any definitive conclusions about the safety and efficacy of proton beam radiation therapy (PBRT) for the treatment of soft tissue sarcomas. Some of the studies regarding PBRT primarily focus on treatment planning and dosimetric data for Proton Beam Radiation Therapy. This is a rare sarcoma of skin and no published data for proton beam therapy is available. The attending physician has not provided dose volume histogram (DVH) comparison of proton beam and intensity modulated radiation therapy (IMRT).
Further randomized controlled trials comparing protons with photons are needed to determine the long term safety and efficacy of proton beam radiation therapy (PBRT) for the treatment of patients with soft tissue sarcomas. The National Comprehensive Cancer Network (NCCN) guideline states that the safety and efficacy adjuvant radiation techniques which includes proton therapy have yet to be evaluated in multicenter randomized controlled studies. It is not  in accordance with generally accepted standards of medical practice in the United States and is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carcinoma of the right breast.

Treatment: Radiation therapy for breast cancer.

The insurer denied coverage for radiation therapy for breast cancer.

The denial is upheld. 

This is a female patient diagnosed with carcinoma of the right breast.  The patient had undergone an ultrasound-guided core biopsy revealing invasive differentiated ductal carcinoma spanning 7 mm (millimeters). The patient was estrogen receptor (ER) negative, progesterone receptor (PR) negative, human epidermal growth factor receptor 2 (HER2) negative, and Fluorescence in situ hybridization (FISH) amplification negative.  She was treated with doxorubicin plus cyclophosphamide chemotherapy and completed 4 cycles.  She then had 12 cycles of dose-dense (DD) Taxol with 4 cycles of carboplatin completed.  She then underwent a right breast wire-guided lumpectomy, sentinel lymph node biopsy, and axillary lymph node dissection.  She saw a secondary provider and they discussed the role of capecitabine and possible pembrolizumab trial after completion of radiation therapy.  The provider referred the patient for consideration of proton beam therapy.  Additionally, the provider recommended the patient undergo a repeat positron emission tomography (PET) scan prior to initiation of radiation treatment to assess current status of the lymph node involvement. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Radiation therapy for breast cancer is not considered medically necessary for this patient.

Proton radiation is generally accepted as medically necessary for the following conditions: 1. intracranial arteriovenous malformations (AVMs); 2. Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body, and choroid); or 3. Skull-based tumors (e.g., chordomas or chondrosarcomas).  All other clinical situations are generally either medically unnecessary or investigational. National Comprehensive Cancer Network (NCCN) Guidelines version 3.2021 for Breast Cancer describes appropriate postoperative radiation as intensity-modulated radiation therapy (IMRT) photons or other conformal techniques, including proton therapy. They also indicate that the best management for any patient with cancer is in a clinical trial. The American Society of Radiation Oncology (ASTRO) Report on Emerging Technologies indicates the proton beam therapy for breast cancer, while not necessarily a standard of care currently, may be considered in appropriate situations. 

The patient is diagnosed with clinical stage IIIC carcinoma of the right breast. The records noted that the patient is appropriate for a clinical trial. However, it does not indicate that the patient is currently enrolled in the clinical trial. There was no proton versus photon plan provided to support the superiority of proton beam therapy.  Therefore, the requested radiation therapy for breast cancer is not medically necessary.

The insurer's denial of coverage for radiation therapy for breast cancer is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 Diabetes.
Treatment: Durable Medical Equipment  (K0553 x 6, K0554 x1) (continuous glucose monitoring device), Pre-service.

The insurer denied the Durable Medical Equipment  (K0553 x 6, K0554 x1) (continuous glucose monitoring device), Pre-service.  The denial is overturned. 

The patient is a female diagnosed with antibody positive type I diabetes. This request is for CGM (continuous glucose monitor) FreeStyle Libre Durable Medical Equipment (K0553 x 6, K0554 x1). As reported, the patient is a brittle diabetic. She has rare hypoglycemic episodes; she has occasional hyperglycemic episodes. She is on Lantus 60 units; Novolog three times a day with meals using carbohydrate coverage as well as high glucose correction. She tried and failed metformin, due to increased abdominal pain, and Glipizide, due to weight gain.

The patient's A1C (glycated hemoglobin) was 8.9%. Previously it was 9.1%. Earlier in the year it was 8.1%. The previous year it was 9.9%.


Her C-peptide (connecting peptide) was <0.10; GAD65 (glutamic acid decarboxylase 65-kilodalton isoform) was 119; ZnT8 (zinc transporter 8) AB (antibody) =<10. Log sheet reveals glucoses ranging between 84 and 414.

Yes, the Durable Medical Equipment  (K0553 x 6, K0554 x1) (continuous glucose monitoring device) is medically necessary.

The requested device is a flash glucose monitoring system (1-4) that is FDA (United State Food and Drug Administration)-approved for persons age 18 and older with diabetes. It has been shown to be effective in patients with type I and II diabetes who are on an intensive insulin therapy. It was associated with sustained reduction in hypoglycemia and safely and effectively replaced blood glucose monitoring (5, 6).

The patient is on an intensive insulin regimen and has type I diabetes. The patient's diabetes is brittle, as the glucoses range widely. The patient's hemoglobin A1C (glycated hemoglobin) is not at goal despite compliance with her insulin regimen and blood glucose monitoring. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health/Depression.
Treatment: Mental Health: Inpatient.
The health plan denied the continued inpatient mental health stay as not medically necessary. 
The health plan's determination is upheld.

The patient is an adult male who presented to the emergency department and was medically screened and admitted to acute inpatient mental health treatment for depression and suicidal ideation in the context of medication non-adherence and intermittent substance use with alcohol and tobacco. The patient presented to the emergency department with an exacerbation of his mood disorder best characterized as recurrent and moderately severe major depressive disorder with comorbid chronic schizophrenia. He self-referred with an emergency evaluation that revealed uncontrolled diabetes mellitus and hypertension and obesity with a body mass index (BMI) of 43, as well as chronic headaches. He was generally cooperative but guarded in the emergency department with a vague plan for suicide prompting his admission for further evaluation and treatments/stabilization of his co-occurring psychiatric and substance-related disorders.

The health plan's determination of medical necessity is upheld.

No, the requested health service/treatment of Inpatient Mental Health Stay is not medically necessary for this patient.
For the time interval under review, the patient's mental disorder and co-occurring substance use disorders could have been effectively managed with lower-level services in this case scenario. Based upon the diagnosis, presenting clinical features, and hospital course, the patient did not require inpatient level structure or monitoring or the intensity of an inpatient level treatment setting.
The patient was admitted to acute inpatient mental health services due to worsening symptoms of depression and suicidal ideation in the context of co-occurring substance use disorder, and in the context of non-compliance and medication non-adherence. For the dates of service under review, the patient consistently denied suicidal ideation, and did not show cognitive impairment or overt symptoms of psychosis. He did not exhibit severe symptoms of a mood or thought disorder, cognitive impairment or perceptual disturbance pertinent to his primary diagnosis of major depression or schizophrenia. Speech and communication skills were intact. The patient maintained his daily activities--- sleep, appetite, energy and volition which were improved and/or okay. He also had access to treatment at a lower level of care with community providers. Thus, the continued stay at the acute inpatient level of care was not medically necessary in this case scenario.

The patient's Continued Inpatient Mental Health Treatment,  could have been safely and effectively provided at a lower level of care. Thus, the continued acute inpatient psychiatric services were not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary
Inpatient hospital

Diagnosis: Hematuria.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a man with a history of hyperlipidemia, hypertension, diabetes, asthma, sleep apnea, and incomplete bladder emptying status post Foley catheter who was admitted to the hospital. He presented because of inability to pass his catheter due to resistance, and he normally performed straight cath at home. He was subsequently able to pass the catheter and this yielded bloody urine with clots. In addition, he reported right flank pain. Review of systems was negative for fevers and chills. Vital signs showed blood pressure 121/77, temperature 98.2 Fahrenheit, heart rate 85, and respiratory rate 16. On physical exam, the abdomen was soft and nontender and a Foley catheter was in place. Labs showed sodium 143, potassium 3.5, creatinine 1.25, glucose 193, calcium 9.4, white blood cell (WBC) 14.15, hemoglobin 14.9, and platelets 172. A computed tomography (CT) of the abdomen demonstrated interval development of a suspicious appearing soft tissue mass in the posterior urinary bladder. The patient was admitted for hematuria and suspected urinary tract infection. 

The inpatient hospital admission was medically necessary. 
The patient presented with evidence of hematuria and clotting, and there was also concurrent urinary tract infection. The patient required continuous bladder irrigation and was at increased risk of development of acute kidney injury, sepsis or continued hematuria in the setting of a possible bladder cancer/mass. Although the patient was never hemodynamically unstable, the complexity of the presentation was consistent with inpatient level of care.
The patient required continuous bladder irrigation, monitoring of electrolytes and kidney function, monitoring of hemoglobin, and intravenous (IV) antibiotics for urinary tract infection. The creatinine at the time of presentation was 1.25 and fell to 0.877 at the time of discharge, indicating that the patient also had acute kidney injury when he presented. Overall, the complexity of the presentation was consistent with the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep disorder. 

Treatment: Hetlioz to treat a sleep disorder.

The insurer denied coverage for Hetlioz to treat a sleep disorder.

The denial is overturned.

This is a female patient with a history of severe delayed sleep phase disorder, obsessive compulsive disorder (OCD), gastroesophageal reflux disease (GERD) and anxiety.  The patient was being evaluated by a Pulmonologist for her sleep disorder.

As per the patient's medical doctor (MD), the patient's symptoms are consistent with a non-24-hour sleep wake phase disorder.  Melatonin had been ineffective in treating the patient.  The patient's MD recommended Hetlioz for treatment of her non-24-hour sleep wake rhythm disorder.  The patient had not responded to the other therapies such as Chronotherapy and Melatonin.  The patient's lifestyle and ability to work is seriously impacted by her condition. 

Melatonin agonists such as tasimelteon (Hetlioz) is a Food and Drug Administration (FDA) approved agent for the treatment of non-24-hour sleep wake disorder in non-blind persons.  As stated in Up to Date, "Tasimelteon is an oral melatonin agonist that was developed for treatment of circadian sleep-wake rhythm disorders. It is our preferred agent in patients who do not respond to over-the-counter melatonin and is an alternative first-line agent in patients who are not comfortable taking an over-the-counter supplement." Since this patient did not respond to all other treatments and has a significant impact to her lifestyle due to her illness it is appropriate to try this medication. 

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

The insurer's denial of coverage for the pre-service request for Hetlioz to treat a sleep disorder is overturned.  Medical necessity is substantiated.