Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Endocrine/Metabolic/Nutritional 
Durable medical equipment

Diagnosis: diabetes
Treatment: Dexcom G6 Sensor 
The insurer denied Dexcom G6 Sensor. The health plan's determination is overturned. 

This is a female diagnosed with Type I Diabetes Mellitus. As per the information provided, she has been using a Dexcom G6 successfully. She uses an insulin pump. She also suffers from hypoglycemia and wide glucose excursions. As per visit note, she is on Dexcom; Medtronic pump, Novolog and Lantus.

A formulary exception is indicated in this case. Dexcom G6 Sensor is indicated.
Continuous glucose monitoring systems including real-time systems have Food and Drug Administration (FDA) approval. They are not the subject of Phase I-III clinical trials. The peer reviewed literature supports the long-term use of CGMS (continuing glucose monitoring systems) in adult (&gt;=25 year old) patients. The American Diabetes Association (ADA) position statement on standards of medical care in diabetes published in January 2011, states, "Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower hemoglobin A1C in selected adults (age &gt;=25 years) with type 1 diabetes." 
The formulary alternative, Accu-check products, would not be as effective as the requested product. Dexcom is a continuous glucose monitor and Accu-check glucose monitor is not continuous. Therefore, a formulary exception is indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Edentulous # (number) 18 and 29.
Treatment:  D6010 implant placement, tooth 29; D6010 implant placement, tooth 18.

The insurer denied coverage for D6010 implant placement, tooth 29; D6010 implant placement, tooth 18.  The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, treatment/progress notes of varying dates with several doctors, narrative letter, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion status post orthodontic care regarding prosthetic rehabilitation for the mandible in the areas of edentulous # 18 and 29. The dentists/surgeons recommended endosteal implants in areas as enumerated above. These clinicians are recommending endosteal implants for masticatory efficiency. The insurer has denied the aforementioned services, stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such a condition, and therefore the endosteal implants and related services are considered not medically necessary, considered elective, and therefore no benefit is available. The insurer suggests that either removable partial dentures or conventional fixed bridge placement are covered and allowed alternative therapies. The patient is appealing the decision.

Upon review of the objective documentation which primarily consists of the panoramic radiograph and treatment notes, the patient exhibits oligodontia and is missing #18 and 29. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures or a fixed denture prosthesis/bridge. In this case the removable partial denture in the mandible would be entirely tooth borne, the most stable and retentive of all removable appliances. Further the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable partial dentures or a fixed bridge remain standards of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures, the endosteal implants are considered elective and not medically necessary.

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

The medical necessity for D6010 implant placement, tooth 29; D6010 implant placement, tooth 18 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: uterine fibroids
Treatment: transcervical uterine fibroids ablation with ultrasound guidance, radiofrequency, code 0404T
The insurer denied coverage for transcervical uterine fibroids ablation with ultrasound guidance, radiofrequency, code 0404T.
The denial is upheld. 

The patient is a female with complaints of 2 days of heavy periods. She was diagnosed with uterine fibroids.

Magnetic resonance imaging (MRI) documented the presence of 2 (two) intramural fibroids measuring 6.5 cm (centimeters) and 1.5 cm (centimeters).

The patient refused hormonal treatment, embolization and surgery and is requesting coverage for transcervical uterine fibroids ablation with ultrasound guidance, radiofrequency, code 0404T.

The Sonata system is Food and Drug Administration (FDA) approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids. The use of the Sonata system in this patient's case is not indicated as some of the fibroids are greater than the 5 cm (centimeters) size that is reported in all the published studies about the efficacy and safety of Sonata. In other words, there are no data about the effectiveness of the Sonata system in patients with larger fibroids. There is suggestion that larger fibroids above 5 cm (centimeters) may require the application of multiple ablations (i.e., multiple procedures).

In summary the use of the Sonata system to manage fibroids above 5 cm (centimeters) is still considered experimental/investigational and therefore not a covered service.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for transcervical uterine fibroids ablation with ultrasound guidance, radiofrequency, code 0404T services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

This is a female with follicular lymphoma. The patient has undergone an outpatient autologous stem cell transplant and presented to urgent care with a temperature of 100.5 degrees at home and worsening mucositis limiting oral intake. The patient was found to be neutropenic and was admitted for inpatient care. 

The inpatient stay is medically necessary.
By virtue of this patient's stem cell transplant and profound cytopenias, this patient met criteria for high-risk neutropenia. Despite empiric antibiotics, the patient continued to spike a fever. The care provided to this patient over the course of her hospitalization was consistent with the peer-reviewed literature and national guidelines. It was not solely supportive in nature. Upon engraftment, resolution of infectious concerns/issues, and treatment of her engraftment syndrome, the patient was promptly discharged. The care provided is consistent with recommendations in the National Comprehensive Cancer Network (NCCN), peer-reviewed literature, and authors of UpToDate. In this clinical scenario, the inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The health plan's determination is upheld.

This is a male patient who presented to the emergency department after a witnessed seizure at home. The emergency medical services were called to the home. The patient was given Versed for seizure and postictal agitation. When the patient presented to the emergency room, he continued to have agitation and was treated with Keppra and phenobarbital. The patient was admitted to the hospital. On admission to the medical floor, the patient's mental status had improved and he requested discharge but was advised to not leave the hospital. He left against medical advice. At issue is the medical necessity of an inpatient stay.
The requested acute inpatient admission is not medically necessary. The patient had a seizure at home and had some ongoing agitation in the ambulance and emergency department. The symptoms were adequately treated in the emergency department when the patient was given Versed, Keppra, and phenobarbital. On admission to the hospital, the patient was noted to have an appropriate mental status and requested to discharge from the hospital. The patient did not have any acute finding on brain imaging. The patient did not have a persistent neurologic deficit. The patient did not have status epilepticus. The patient did not have prolonged postictal confusion as the patient was able to request discharge home. All of these findings suggest that care at a lower level was most appropriate for this patient. The patient was stabilized during the observation time frame and in the emergency room.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems
Treatment: Crown (D2750) for tooth #30
The insurer denied the crown (D2750) for tooth #30.
The determination is overturned.

The patient presented for the treatment of tooth number (#) 30. Provided for review are health plan language, a letter from the patient, patient consent to record release, letters of denial, explanation of benefits, a single page of American Dental Association (ADA) claim forms, and multiple radiographic images. At issue is the medical necessity of the crown for tooth number (#) 30.

The requested health service/treatment of crown for tooth #30 is medically necessary for this patient as there is decay that is extensive and involving the pulp, and a direct restoration cannot be fabricated in a case like this. Thus, there is a requirement for removal of the affected tooth structure and creating a tooth form that will prevent further fracture of the tooth and restore the cusp. Hence, the crown for tooth #30 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glioblastoma
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This patient was admitted for medical reasons and was transferred, after presenting with progressively worsening mental status, to the admitting hospital.

Patient underwent a partial microsurgical resection of frontal glioblastoma. He had a fall while walking outside and hit his head, leading to transfer admission. 

Computed tomography (CT) showed unchanged multifocal bifrontal hemorrhages, no new hemorrhage. There was ongoing evidence of cerebral dysfunction.

The patient received radiation treatment which is generally done as an outpatient.  If the patient needs nursing home care or rehabilitative care, the patient is generally transferred every day for radiation. There is no need to keep patient in hospital for radiation.

Based on the above, the insurer's denial must be upheld. 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 the continued full hospital admission from is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malpositioned Teeth.
Treatment: Braces, monthly visits.
The health plan denied: Braces, monthly visits.
The determination is: Upheld.

The patient is a female with a Class I occlusion with 3-millimeter (mm) overbite and 3 mm overjet. She has moderate maxillary and mild mandibular crowding. She has treatment planned for 24-30 months of orthodontics to correct her malocclusion.
At issue is the medical necessity of braces and 12 monthly visits.

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

The requested health service/treatment of braces and 12 monthly visits is not medically necessary for this patient. She has crowding, but no teeth are impacted. Her overbite is deep, but there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows the lower incisors are not contacting the palate in occlusion. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. The records provided do not support a diagnosis of posterior cross bite. There is no anterior crossbite present.
There is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no detectable anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion.[2] The patient has a 3 mm overjet, but this amount of overjet does not affect oral health related quality of life.[3] If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intraosseous Basivertebral Nerve Ablation.
The insurer denied: Intraosseous Basivertebral Nerve Ablation.
The denial is upheld.

The patient is an adult female with chronic low back pain in whom an Intercept procedure was requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid
injections, home exercise and pain medications. MRI (magnetic resonance imaging) does not show Modic changes. Physical exam does not reveal any neurological injury.

The health plan should not cover the requested Intracept procedure. 

The requested Intracept is not more beneficial. The Intracept procedure (interosseous basivertebral nerve ablation) is not an Intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It has been shown effective in RCT (randomized controlled trials) with 5-year results. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient has not failed or attempted facet joint interventions, which are common treatment of axial low back pain. According to the MRI (magnetic resonance imaging) report, there is no documentation of any Modic changes. Lastly there is evidenced to be a grade 1 
spondylolisthesis, which also can cause back pain. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intraosseous Basivertebral Nerve Ablation.
The insurer denied: Intraosseous Basivertebral Nerve Ablation.
The denial is upheld.

The patient is an adult female with a history of low back pain and neck pain. The patient previously had epidural steroid injection times three without relief. On exam the patient had decreased range of motion lumbar and pain with facet loading. The plan is for a Intracept procedure. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes. The patient has greater than six months of pain and failed greater than six months of treatment. Prior treatments include home exercises, physical therapy, chiropractic therapy, lumbar epidural steroid injection and medication management.

The health plan should not cover the requested Intracept procedure.

Although the patient has a history of axial pain, there were no documented Modic type changes on the MRI (magnetic resonance imaging). Additionally, it was noted that there was facet arthrosis, and there was no documentation of addressing the arthropathy that could cause the axial pain.
Appeal type: Medical necessity
Decision: Upheld


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

This patient is a previously healthy woman who presented to the Hospital emergency department (ED) with the complaint of abdominal pain, nausea and vomiting of 1-week duration. She had been seen for similar complaints. Vital signs at the time of presentation were normal. She had epigastric and right upper quadrant tenderness on examination. Lab data identified elevated liver enzymes and normal bilirubin. The white blood cell count (WBC) count was elevated at 11.14. An abdominal ultrasound showed small gallstones/sludge within the gallbladder. She was admitted to the hospital with the diagnosis of cholecystitis.

Inpatient hospital admission was not medically necessary for this patient. This patient presented with abdominal pain. She had been seen for similar abdominal complaints 5 days earlier. She was clinically and hemodynamically stable at the time of presentation. Her evaluation identified biliary sludge, right upper quadrant pain, leukocytosis and mild elevation of serum transaminases. She was admitted with the diagnosis of cholecystitis.
Although the records and diagnostic test results establish the indication for cholecystectomy, the records do not indicate that cholecystectomy was performed during this admission. Nor is there definitive documentation of the plan for cholecystectomy in the outpatient setting.
The patient was provided IV fluid and follow up lab and imaging assessment. She remained clinically stable during the period of monitoring. This patient's clinical needs could have been satisfied with a lower level of care. This level of care would have provided for clinical assessment and monitoring as was performed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Deficit in receptive and expressive communication.
Treatment:  Outpatient speech therapy (20 visits).

The insurer denied coverage for outpatient speech therapy (20 visits).  The denial is overturned.

The review states clearly that the school district was unable to provide Speech/Language treatment for this child, and there are no providers on the list provided by the district who are available and can accommodate her needs at this time. With a moderate to moderate-severe deficit in receptive and expressive communication, the patient is already demonstrating severe frustration and behavioral outbursts related to her decreased ability to understand and communicate her wants/needs and developing thoughts as a young child. Ultimately, without treatment, this could lead to significant negative impacts on her physical, emotional and educational development.  Additionally, school-based therapy is not equivalent to private therapy, as their goals are, by public law, to facilitate academic progress, versus the overall health and status of the child. 

The denial was based on the fact that the "Board of Education did not specifically state that they cannot provide adequate speech/language services" for the patient. However, the RSA (related service authorization) document exists expressly for this purpose. Unfortunately, they shift their legal burden on to the parent to try to find services from a very long list of providers.  Parent demonstrated due diligence in trying to schedule with multiple providers from this list.

The patient should be able to proceed with the 20 sessions at the clinic where she was making strong, evidence-based progress as shown by serial reassessments and functional status. This is clearly medically necessary, in the context of further work with the school district.

The appeal was very thorough in provision of history and many evidence-based citations regarding the necessity of speech/language treatment for the patient.

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 outpatient speech therapy (20 visits) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Heart muscle weakness
Treatment: Zoll Life Vest
The health plan denied: Zoll Life Vest. 
The determination is: Overturned.

The patient is a male with a history of chronic systolic heart failure due to nonischemic cardiomyopathy, hypertension, and end stage renal disease (ESRD) on hemodialysis (HD) who was prescribed a Zoll Life Vest (wearable cardioverter defibrillator [WCD]) after an echocardiogram demonstrated decline in left ventricular ejection fraction (LVEF) to 30-35 percent (%). The patient was to continue medical optimization of his guideline directed medical therapy then reassess LVEF by cardiac positron emission tomography (PET).
At issue is the medical necessity of the Zoll Life Vest.
Yes, the Zoll Life Vest WCD prescribed for this patient is medically appropriate and necessary to protect this patient from sudden cardiac death.
Because the patient's LVEF had declined placing him at increased risk for sudden death due to ventricular arrhythmias, the treating provider's recommendation for the patient to wear the WCD was medically appropriate and necessary for sudden cardiac death protection while allowing time for myocardial recovery during medical optimization prior to implantable cardioverter defibrillator (ICD) implantation.
According to the 2017 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death, the WCD is reasonable for patients, not ineligible for ICD, at high risk of sudden death due to life-threatening ventricular arrhythmias with LVEF 35% or less during the 90-day waiting period while monitoring for recovery of cardiac function [3]. For these reasons, the WCD is medically appropriate, necessary, and beneficial in this case to protect this patient against ventricular arrhythmias while allowing time for myocardial recovery during medical optimization prior to ICD implantation.