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

Diagnosis: Cataract
Treatment: CPT (Current Procedural Terminology) code C1889
The insurer denied coverage for CPT code C1889.
The denial is upheld.

This case involves an adult who was working as a carpenter when a splinter went into his eye at work. While the injury healed, the patient developed a cataract in the left eye. A laser assisted cataract extraction with intraocular lens (IOL) of the left eye was completed. When the patient was seen, the reason for the visit was a check regarding nuclear sclerotic cataract of the right eye. The patient was status post left eye surgery and was happy with his vision on the left. The physician stated the cataracts are mild and had minimal impact on the patient's vision at that time. The patient received a notice of adverse determination regarding CPT (Current Procedural Terminology) code C1889. The indication was that the reviewer was unable to determine what specific services the unlisted code represented. Records indicated the treating physician requested the service for the evaluation of nuclear sclerotic cataract of the left eye. The patient was seen for a 5-month postoperative check of the left eye and continued to have issues with the nuclear sclerotic cataract of the right eye. The patient was improving following the left eye surgery with intraocular pressure was read at 12 bilaterally. Visual acuity was 20/20 on the right and 20/20- 1 on the left. This review pertains to CPT code C1889 that was denied coverage as an ineligible service for payment.

Current medical literature notes that intraocular lenses replace an eyes natural lens during cataract surgery. The documentation provided for the review stated the patient underwent cataract extraction surgery. While surgery was reasonable, the service and question pertaining to CPT code C1889 indicated as implantable/insertable device, not otherwise classified. Previously, the patient was denied coverage for the service as there was no confirmed information given regarding to what the specific service was pertaining. The appeal letter claimed that the physician had requested the service for the evaluation of nuclear sclerotic cataract of the left eye. However, there was no explanation given for what in this particular code pertained to and how it was related to evaluation of nuclear sclerotic cataract. Given that no further information was received from the treating physician, the prior determination is upheld as the medical necessity of the request could not be established.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for denial of services described by CPT code C1889 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity 

Treatment: ambulatory surgery/surgical procedure (15830x1, 15847x1) to remove excess skin from abdomen after weight loss

The insurer denied coverage for ambulatory surgery/surgical procedure (15830x1, 15847x1) to remove excess skin from abdomen after weight loss

The denial is overturned
 

A panniculectomy (15830) and abdominoplasty (15847) are medically necessary.  According to the American Society of Plastic Surgeons Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients", "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." 

The records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment by her primary care physician (PCP) for four months. Photos show rashes and skin changes under the pannus fold and in the umbilicus. She has a double pannus and panniculectomy alone will not be sufficient to remove both abdominal folds. A panniculectomy and abdominoplasty are required to correct the umbilical hooding and remove both pannus folds.  

The patient has failed medical management, and the procedures are required to treat her rashes. 

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 ambulatory surgery/surgical procedure (15830x1, 15847x1) to remove excess skin from abdomen after weight loss (panniculectomy and abdominoplasty) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recent subdural hematoma, dementia, coronary artery disease, glaucoma, hypertension, shortness of breath, and spinal surgery. 
Treatment: Increase in Personal Care Worker (PCW) Services to 7 Days per Week, 12 Hours per Day, 84 Hours per Week. 
The insurer denied: Increase in Personal Care Worker (PCW) Services to 7 Days per Week, 12 Hours per Day, 84 Hours per Week. 
The denial is overturned. 

This elderly male patient has medical conditions that include a recent subdural hematoma, dementia, coronary artery disease, glaucoma, hypertension, shortness of breath, and spinal surgery. The patient lives alone. The denial of an increase in personal care worker (PCW) services to 7 days per week, 12 hours per day, 84 hours per week is being appealed. The plan approved 7 days per week, 9 hours per day, 63 hours per week. 
Uniform Assessment System evaluation completed nine months ago shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, and lower body dressing; extensive assistance with managing finances, bathing, upper body dressing, and toilet use; limited assistance with managing medications, personal hygiene, walking, toilet, transfer, locomotion, bed mobility, and eating. The patient has bowel and bladder incontinence.
Appeal statements report that the patient needs assistance with all activities of daily living (ADLs), 12x12 hours per day for 7 days per week. He needs to be changed 3 to 4 times during the day and nighttime to urinary and bowel incontinence. He requires assistance with repositioning in bed. The patient is unable to walk or stand on his own. His mental condition is deteriorating. He is a fall risk. He had a fall eight months ago. His condition has deteriorated since that time. 

The proposed treatment is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions, including recent subdural hematoma. The denial of an increase in personal care worker (PCW) services to 7 days per week, 12 hours per day, 84 hours per week is being appealed. The plan approved 7 days per week, 9 hours per day, 63 hours per week. Uniform Assessment System evaluation completed nine months ago shows the patient needs assistance with all activities of daily living and his cognitive and physical functioning have deteriorated since the Uniform Assessment System evaluation, after a fall. The patient lives alone. He needs to be changed 3 to 4 times during day and nighttime to urinary and 
bowel incontinence and requires assistance with repositioning in bed. The information provided shows that this patient has significant limitations in functioning. The approved personal care worker 63 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 84 hours per week is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Constipation

Treatment: Motegrity (prucalopride)

The insurer denied coverage for Motegrity (prucalopride)

The denial is upheld
 

According to the medical records the patient has constipation. The request is for Motegrity (prucalopride) as treatment for this condition. 

The plan declined coverage as the member did not try and fail three formulary alternative medications for their condition. There was insufficient information that the member had tried and failed at least three formulary preferred medications for this condition. The member tried and failed over-the-counter options instead. There was no reason provided to indicate the patient could not trial both formulary alternatives. As such, the request is denied.

"Diagnosis involves identification of the neurologic disease and its distribution, and documentation of segmental gut dysfunction, typically using noninvasive imaging, transit measurements, or intraluminal measurements of pressure activity and coordination of motility. Apart from treatment of the underlying neurologic disease, management focuses on restoration of normal hydration and nutrition and pharmacologic treatment of the gut neuromuscular disorder." (Camilleri, M. 2021).

"The Food and Drug Administration (FDA) has also approved prucalopride and lubiprostone for chronic idiopathic constipation. However, there continues to be a debate about the safety of these agents in the long run and caution is advised against starting patients on these drugs." (Diaz, S. et al. 2023).

The formulary drugs are not expected to cause adverse effects. 

Both formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Motegrity (prucalopride) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder (tooth # 31). 
Treatment: Crown for Tooth # 31. 
The insurer denied Crown for Tooth # 31. 
The determination is upheld. 

The patient is a male who presented for the treatment of tooth number (#) 31 with a porcelain crown. Provided for review are multiple pages of appeal and denial, radiographic images, a treatment ledger, a narrative from the patient, claim forms, health plan language regarding medical necessity, and a narrative by the treating doctor. At issue is the medical necessity of the treatment of porcelain crown for tooth #31. 

The provided documentation does not support the medical necessity of a crown for tooth #31 for this patient. For treatment to be necessary there needs to be documentation that supports the medical necessity, however, this case does not show any such evidence that the tooth requires removal of tooth structure that necessitates full coverage. Hence the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Hospital admission
The insurer denied: Hospital admission
The denial is upheld.

The patient is an adult male with a history of chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). He is an active smoker who presented to the emergency room with cough and productive cough. The patient had tried and failed outpatient treatment. The patient was found to have pneumonia during the emergency room workup. The 
patient was started on supplemental oxygen and intravenous antibiotic and was admitted to acute in-hospital level of care. The patient received oral prednisone, DuoNebs, and antibiotics. The 
patient was discharged home the next day. The acute hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was not medically necessary.

The patient was admitted to hospital for pneumonia. At the time 
of admission, the patient was hemodynamically stable. The patient was not in respiratory distress. He was able to tolerate oral diet and was able to ambulate. The patient was on minimal supplemental oxygen. The patient did not receive any treatment that could not have been safely and effectively provided at a lower level of care. The acute hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enterovirus-rhinovirus. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a toddler male child with medical history significant for eczema and previous hospitalization for COVID/adenovirus infection that presented to the emergency department with two-day history of nasal congestion, cough with post-tussive emesis, difficulty breathing, wheezing, and decreased intake. Vital signs included temperature 100.0, heart rate 117, and respiratory rate 36. Examination was significant for mild distress with tachypnea, moist mucous membranes, tachypnea with rate 66, retractions, wheezing, benign abdomen, and non-focal neurologic exam. Laboratory evaluation revealed positive screen for enterovirus-rhinovirus. Chest x-ray revealed hyperinflated lungs with peribronchial cuffing. The patient was treated with DuoNebs, Tylenol, albuterol, and dexamethasone, and subsequently was admitted for ongoing treatment of reactive airway disease secondary to viral bronchiolitis.
Admission orders included regular diet, albuterol every three hours, Atrovent for four doses, Prelone every twelve hours, and Benadryl for congestion. Upon arrival to the floor, the patient's respiratory rate was 67, with abdominal breathing, transmitted lung sounds, and mild expiratory wheezing. Following a breathing treatment, his rate decreased to the 40s and his abdominal breathing improved significantly. He slept well overnight, with improved formula intake and increased wet diapers. The patient's examination had normalized. An Infectious Disease consultation was placed with no new recommendations. The patient was deemed stable for discharge, to continue albuterol treatments every four hours, complete his course of steroids, and follow-up with his pediatrician in one to two days. 

The acute inpatient admission was not medically necessary. 

This young male infant with history of atopy presented with increased work of breathing, cough, and wheezing. Testing was positive for enterovirus-rhinovirus, and he was diagnosed with reactive airway disease secondary to viral bronchiolitis. He responded well to bronchodilators in the emergency department. He continued to receive bronchodilators with sufficient resolution of symptoms that he was deemed stable for discharge the day after admission. While it was not unreasonable to monitor this patient in the hospital for improvement versus decompensation, he was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung Cancer
Treatment: Proton Beam Therapy
The insurer denied the proton beam therapy.
The health plan's determination is upheld.

The patient is a male who presented with stage 4 lung cancer. He was treated with chemotherapy and radiation. The patient was diagnosed with leptomeningeal disease. He was treated with Proton beam treatment.

The requested health service/treatment of Proton Beam Radiation Therapy is not medically necessary for this patient. Medically necessary treatment is defined as those which are in accordance with Generally accepted standard of medical practice. The Health plan does not cover Proton beam for this condition. The generally accepted standard of medical practice for leptomeningeal disease is conventional photon-based treatment.
National Comprehensive Cancer Network (NCCN) guidelines do not suggest Proton beam for this palliative treatment. There is no published randomized trial to support clinical superiority to support Proton beam. Generally accepted standard of medical practice for leptomeningeal disease is conventional photon-based treatment.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, vomiting, diarrhea, and sore throat 
Treatment: Full hospital admission 
The insurer denied coverage for the full hospital admission. 
The denial is upheld. 

This is a child with a history of autism spectrum disorder who presented to the emergency department (ED) with fever, vomiting, diarrhea, and sore throat complicated by anorexia and inability/refusal to eat. 

ED vital signs were febrile (temperature up to 103.2 degrees Fahrenheit), tachycardia 134 beats per minute, dry buccal membranes, erythematous pharynx with tonsillar exudates, and evidence of purulent left otitis media. 

Laboratory results showed mild abnormalities of clinical significance: hyponatremia [sodium 133 mmol/L (millimoles per liter)], respiratory viral panel positive for Adenovirus. Bicarbonate was mildly decreased at 19 mmol/L. 

The ED physician noted that the patient needed to be admitted for dehydration and poor oral intake. However, urine ketones were negative and Blood Urea Nitrogen (BUN) less than 5, so there was no objective evidence of dehydration.

The patient had evidence of pharyngitis from proven adenovirus infection, but he had no objective evidence of dehydration. He was not described as very ill-appearing or toxic. His throat exam did not reveal evidence of obstruction, tonsillar abscess, trismus, drooling, or deviation of uvula from the midline, that would interfere with oral intake. There is no documentation of a trial of oral fluids and the medical justification for admission, as stated, is insufficient. Supportive care for acute pharyngitis in children includes symptomatic treatment, oral trial of fluids, and a soft diet. This could have been tried during a period of observation.

Even if we assess the patient as having mild dehydration, per current literature on management of dehydration in children, and using the CHOP (Children's Hospital of Philadelphia) clinical pathways, a trial of oral rehydration following a bolus of intravenous (IV) fluids should be done, especially as there were no ongoing losses (there was no ongoing vomiting or diarrhea). He could have been sent home on amoxicillin after a single dose of ceftriaxone.

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

Central Nervous System/Neuromuscular.
Advanced Imaging Services.

Diagnosis: Memory Impairment.
Treatment: MRI of the Brain.
The insurer denied the MRI of the Brain.
The determination is overturned.

This is a female patient who is requesting evaluation by magnetic resonance imaging (MRI) of the brain for memory impairment. The study was originally denied because supporting information was not submitted to demonstrate memory impairment, such as a standardized mental status examination. The appeal includes a mini mental status evaluation showing a score of 26/30 indicating mild cognitive impairment. At issue is the medical necessity of a brain MRI.
MRI of the brain is medically necessary for evaluation of the patient's cognitive impairment. The study was originally denied because documentation was not submitted supporting the diagnosis of memory loss or cognitive impairment. However, there is a standardized mini mental status examination provided for review. This evaluation shows that the patient scored 26/30. This score indicates mild cognitive impairment. The standard of care for evaluation of cognitive impairment includes a laboratory evaluation. The laboratory evaluation did not show any reversible causes of cognitive impairment. The next part of the evaluation is to obtain imaging of the brain. As such, the requested study is consistent with the standard of care and medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented to the emergency department (ED) with chest pain. The patient reported several years of chest pain. His chest pain was described as when walking half a block, he feels chest tightness and pressure. The most recent episode was the day prior to presentation and resolved with rest. He also was getting shortness of breath with minimal exertion.
The patient initially was admitted and underwent cardiac catheterization and was diagnosed with severe three vessel coronary artery disease (CAD) and was about to undergo coronary artery bypass graft (CABG). However, the patient left the hospital against medical advice (AMA) and then presented to this hospital.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented to the hospital and work-up revealed severe 3 vessel coronary artery disease (CAD), and coronary artery bypass graft (CABG) was planned. However, the patient left and went to another hospital of his choice. During the hospital stay, his condition was stable. His vital signs were normal. His physical examination was unremarkable. His electrocardiogram (ECG) did not have ischemic changes. His chest x-ray (CXR) did not reveal evidence of congestive heart failure (CHF). The patient's troponin and brain (or B-type) natriuretic peptide (BNP) were normal.
The patient stayed at the hospital awaiting films from another hospital. It took 3 days to obtain films from another hospital. There are no indications for the patient to stay inpatient and wait for films arrival. The patient was stable for discharge and could be scheduled for CABG as an outpatient.
The patient was treated with intravenous (IV) Lasix and IV Nitroglycerin, but this management was not indicated. The patient was comfortable, without evidence of congestive heart failure (CHF) or unstable angina. A lower level of care was appropriate.