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

Diagnosis: Dental Problems/Overbite/Underbite
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested dental treatment plan. The health plan's determination is upheld.

The patient is a female with Skeletal Class I with Class II canine malocclusion, moderate maxillary crowding and moderate mandibular crowding, and moderate overjet and moderate overbite with moderate incisor protrusion. The subject to be determined is the medical necessity for braces and monthly visits.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 17 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces and monthly visits are not medically necessary for this case.

With the case's amount of crowding and flaring of the incisors, the provider's treatment plan of 30-36 months with first premolars extractions look appropriate and is the standard of care. The provider must make sure to have proper posterior anchorage including an appliance such as a transpalatal arch (TPA) or a Nance to prevent excessive mesialization of the posterior segments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: syncopal episode and fall
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male. He has a past history of alcohol abuse, hypertension, PTSD (post-traumatic stress disorder), anxiety and bilateral knee osteoarthritis. He had a syncopal episode and fell. He also had incontinence. He reported right ankle pain. EMS (emergency medical services) were called to the scene. He was then transported to hospital.

The patient was admitted to hospital where consultations were completed. He underwent imaging which showed a complex distal tibia fibula fracture (fracture dislocation). He underwent open reduction internal fixation (ORIF) to his fracture. The duration of surgery was over three hours. His ASA (American Society of Anesthesiologists) score was 3. Neurology consultation opined alcohol withdrawal seizure. Psychiatry consultation was completed for paranoia. He received PT (physical therapy) services with satisfactory progress.

Yes, the Inpatient admission was medically necessary.
The records demonstrate a complex clinical scenario. The patient has several problems which required evaluation and treatment. Each by themselves would not be sufficient for hospitalization, but in combination, inpatient services would be appropriate.

There was evidence of syncope with unknown head trauma. The incontinence and diagnosis of new seizure required Neurology evaluation. Imaging studies were required to rule out intra-cranial and vascular problems. The patient required treatment for his "newly diagnosed alcoholic withdrawal syndrome."

The fracture dislocation to ankle required operative intervention. The operation was complex and extensive. The physician placed three surgical incisions to treat fractures and syndesmosis disruption. The operation/anesthesia team was over three hours. This type of surgery is not performed in an ASU (ambulatory surgical unit). Post-surgical monitoring is important with sufficient analgesia.

The patient had a psychiatric problem and reported paranoia. He required psychiatric consultation. The physician contacted his treating psychiatrist and made recommendations.

The MCG (Milliman Care Guidelines) for ankle notes extended stay for comorbidities. The records show syncope, head trauma and psychiatric problems.

The MCG (Milliman care guidelines) for syncope notes extended say for syncope related conditions (head trauma and ankle fracture).

Therefore, given the above, the admission and length of stay were thus appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Taclonex 
The insurer denied the Taclonex.
The determination is upheld.

The patient has psoriasis of the scalp and ears. The patient was noted to have used fluocinolone oil with temporary improvement. Clotrimazole solution did not help. Mometasone was difficult to apply to the itch in the ears. Formulary alternatives include Calcipotriene 0.005% (ointment, solution) Betamethasone dipropionate 0.05% (cream, lotion, ointment). suspension was prescribed, and the medical necessity of Taclonex is under review.
The Taclonex is not medically necessary.  Current medical literature [1-5] supports the use of high-potency topical steroids as one form of topical treatments for psoriasis of the scalp and ears, just as this literature supports use of topical calcipotriene as well. The same current medical literature does not support use of combined calcipotriene and betamethasone over the use of either treatment used alone in tandem with the other. High-potency topical steroids alone may resolve this patient's psoriasis and itching. Accordingly, the requested Taclonex suspension, while one form of treatment for this patient's condition, is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nasal obstruction
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has sleep apnea. His apnea hypopnea index (AHI) was 50. The patient was on continuous positive airway pressure (CPAP). His history was significant for a previous tonsillectomy, adenoidectomy, septoplasty, and lingual tonsillectomy.
He underwent a revision adenoidectomy and septoplasty, and turbinoplasty. Postoperatively nasal cannula oxygen was needed in the post-anesthesia care unit (PACU). He was transferred to the pediatric intensive care unit (PICU) and started on his CPAP. An appeal note stated that patient's oxygen saturation remained above 90% throughout the hospital stay without supplemental oxygen. There were no peri-operative complications.
At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary. Although the patient had severe sleep apnea, there were no intra-operative or peri-operative complications. There was no documentation of abnormal vital signs, bleeding, or difficulty breathing. The patient already was on CPAP. The patient did not have oropharyngeal surgery.
The patient could have been managed at a lower level of status which allows for overnight stay. Under this level of care the patient could have had continuous pulse oximetry monitoring and could have also used his CPAP. A lower level of care would be considered standard of care. Inpatient level of care is not supported by the literature as improved outcomes and decreased complications have not been demonstrated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: postoperative infection

Treatment: physical therapy

The insurer is denied coverage for physical therapy

The denial is upheld. 

This female patient has a history of anterior cruciate ligament (ACL) tear with reconstruction after which she had physical therapy (PT). She had 17 PT sessions. She developed an infection so required arthroscopic debridement. She then had consistent PT sessions.

All of the records provided were reviewed from a physical medicine and rehabilitation physician perspective. The patient is a female who underwent 3 right knee surgeries. She initially had a right knee ACL reconstruction and has 17 sessions of therapy after the initial surgery. She then underwent lysis of adhesions and manipulation under anesthesia. She was in PT consistently and had 99 visits of therapy. She then transferred to another PT location and had 18 sessions of therapy and then another 45 sessions of PT. In total it seems the patient had over 150 visits of PT after her final manipulation under anesthesia surgical procedure. The PT visits and physician notes were reviewed during this period of time. The patient did make progress in her condition over the last year and a half of PT. Her pain complaints have been minimal and her symptoms were reported to be intermittent with only a little interference with her activities of daily living. She has already had well over the recommended amount of PT visits post surgery and has made progress. After over 150 sessions of PT she should be well versed in a home exercise program and should be able to continue making progress with a home exercise program without the need of supervised one on one PT. There is a lack of documentation indicating the patient is unable to perform a home exercise at this point and the period of therapy in question as well as additional PT was not medically necessary.



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 physical therapy is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency ward with the complaint of dizziness and hand tingling for four days. At presentation, the patient had a normal neurological examination and computed tomography (CT) of the brain was negative. The patient also reported having a previous episode of dizziness in the past and she refused magnetic resonance image (MRI) after admission.

No, the proposed treatment, inpatient admission, was not medically necessary.
The patient presented with a four day history of non-specific symptoms that were not likely to represent a cerebral ischemic event. Based on current risk stratification guidelines for transient ischemic attack (TIA), the patient did not meet criteria for acute inpatient level of care as the probability of subsequent stroke was very low. The treatment, monitoring and diagnostic studies could have ben safely and effectively provided at a lower level of care.
Appeal type: Out-of-Network Service
Decision: Overturned

Diagnosis: Gender Dysphoria/Gender Dysphoria
Treatment: Surgical Services
The health plan denied the out of network request. 
The health plan's determination is overturned. 

This is a patient with gender dysphoria and status post male to female transgender surgery. The patient underwent vaginoplasty complicated by vaginal strictures that was repaired three times. She currently has vaginal stenosis with only 2 inches of vaginal depth. Due to her previous surgeries to correct the vaginal stenosis of using peritoneal tissue and skin grafting, she has no options to further dilate the depth of her vagina. The patient is seeking an out of network provider for a colovaginoplasty revision. The patient has seen an in-network provider who has performed 4 colovaginoplasty revisions and is uncomfortable with the provider.
At issue is whether the out-of-network health service is materially different from the in-network health service.

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

Yes, the proposed out-of-network health service is different from the alternate recommended in- network health service in that the out-of-network provider is far more experienced in performing this already unique procedure. The in-network provider has little experience with the requested procedure. The patient has had multiple failed reconstructive attempts and does not have many surgical options to solve her vaginal stenosis.
This patient is unique in that she has had multiple complications and failed reconstruction to create a neovagina. There are few providers in the United States who perform this procedure and comparing between the in-network provider with the out-of-network provider, the out-of-network provider is far more experienced in this rare procedure. The potential for success for the procedure is most likely higher with the out-of-network provider.
Appeal type: Medical necessity
Decision: Overturned in Part

Orthopedic/musculoskeletal
Physical therapy

Diagnosis: shoulder surgery
Treatment: Physical therapy (PT)
The insurer denied physical therapy. The health plan's determination is overturned in part. 

The patient is a male with medical history significant for left total scapulectomy for osteosarcoma with reconstructive surgery involving the use of a custom fabricated scapula prosthesis. Under review is the medical necessity of physical therapy (PT) services.

Physical Therapy was medically necessary for 2 months. After 2 months, no documentation was provided to support continued PT. The patient underwent left total scapulectomy with scar body reconstruction and rotator cuff capsular reconstruction. He had home therapy for approximately 3 weeks and then began outpatient physical therapy with direction to remain in sling for 12 weeks post-op. First off, 12-week post-op restriction to sling is very normal given this type of surgery. This restriction, though, lead to slower progress as there were limitations. Regardless of those limitations, therapy documentation did show progress. For example, despite the patient reporting increased soreness once splint had increased past 45 degrees his QuickDASH disability score had still decreased from 65 to 45%. Also, while he regressed with active range of motion (AROM) in flexion and abduction (felt to be 2/2 the increased soreness) he still improved with passive range of motion of left shoulder flexion (105 to 128 degrees) and left shoulder abduction (130 to 135 degrees). He continued to make progress as was described during re-evaluation when his DASH score further decreased to 22% and his active shoulder flexion improved from 65 to 75 degrees.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diffuse large B cell lymphoma.
Treatment: CPT 78816 PET W CT Whole Body, Pre-service.
The insurer denied the CPT 78816 PET W CT Whole Body, Pre-service.
The denial is overturned.

The patient is a male with diffuse large B cell lymphoma (DLBCL) of the lumbar spine (extranodal site excluding the spleen and other solid organs) requesting a whole body PET/CT (positron emission tomography/computed tomography) scan. The patient was treated with modified RCHOP (Rituximab, Cyclophosphamide, Hydroxydaunomycin, Oncovin, Prednisone) with ITT (intrathecal therapy), and HD-MTX (high-dose methotrexate), which was completed. The end of therapy PET/CT (positron emission tomography/computed tomography) demonstrated residual positive uptake potentially representing residual disease, and a follow-up PET/CT (positron emission tomography/computed tomography) was ordered.

Yes, the 78816 PET (positron emission tomography) CT (computed tomography) Whole Body is medically necessary.

The end of therapy PET/CT (positron emission tomography/computed tomography) for this patient's diffuse large B cell lymphoma (DLBCL) demonstrated residual positive uptake at the site of the L3/4 (third lumbar spine vertebra/fourth lumbar spine vertebra) laminectomy, potentially representing residual disease versus post-surgical changes, and a three-month follow-up PET/CT (positron emission tomography/computed tomography) was ordered.

The NCCN (National Comprehensive Cancer Network) Guidelines B-Cell Lymphomas, version 4, states that for continued disease that chemotherapy treatment is recommended, however, there is uncertainty that this patient's PET/CT (positron emission tomography/computed tomography) findings represented residual disease versus post-operative changes. Administering chemotherapy in this situation is not warranted, and a "wait and see" course would be the best treatment option with a follow-up PET/CT (positron emission tomography/computed tomography) to reassess the area in question.

Therefore, given the above, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: short stature.
Treatment: Norditropin.
The insurer denied Norditropin. 
The health plan's determination is upheld. 

The patient is a male who is seeking growth hormone (GH) treatment under the indication of short stature associated with being born small for gestational age (SGA). He was born after 37 4/7 weeks of gestation and his birth weight was 5 lbs (pounds)15 oz (ounces) (2693 grams). His mother's height is 64'' while father's height is 70''. By history, he is growing just below 5th percentile for his height, and his growth velocity is normal

Norditropin is not medically necessary for this patient.

Consensus statement of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society proposed that "children born SGA with height below 2.5 SD scores (SDS) at the age of 2 years or with height below 2 SDS (standard deviation score) at the age of 4 years should be eligible for GH treatment".
This patient's height was not 2.5 SD below the mean to qualify for GH under SGA indication. Although this patient is quite short for his age and genetics and his most recent reported height was 2.3 SD below the mean for age, his weight is affected even more and was 2.5 SD below the mean for age suggesting nutritional growth retardation as the cause of slow growth rather than SGA. Patients with nutritional growth retardation may cease to gain appropriate weight and fail to grow in height even without exhibiting body weight deficits for height.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prediabetes
Treatment: Trulicity 0.75mg/0.5ml SC SOPN (Pre-service)
The insurer denied the Trulicity 0.75mg/0.5ml SC SOPN (Pre-service)
The denial is upheld. 

This is a male with pre-diabetes, nonalcoholic steatohepatitis, dyslipidemia, and obesity. His glycated hemoglobin (A1C) was 6.0%.  The request for Trulicity is under review.

No, the proposed Trulicity is not medically necessary.
This patient has prediabetes with an glycated hemoglobin (A1C) of 6.0% and obesity. The Endocrine Society guidelines on the management of obesity do not support the use of Trulicity in this clinical situation. The Trulicity prescribing information and the American Diabetes Association clinical guidelines do not support the use of Trulicity for the management of prediabetes. Trulicity has risks, including nausea and vomiting. Therefore, no, the proposed Trulicity is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dense breast tissue
Treatment: Ultrasound of the breast; complete study (76641)
The insurer denied the Ultrasound of the breast; complete study (76641)
The denial is overturned.

The patient is a female with a family history of breast cancer and recent mammography which was negative for breast cancer. However, the test was notable for extremely dense breast tissue, making the study less sensitive.  

Appeal review requested for potential approval of ultrasound of the breast; complete study (76641) to routine breast cancer surveillance screening.

Yes, the proposed treatment, ultrasound of the breast; complete study (76641), is deemed medically necessary.
This is a female with a family history of breast cancer and recent mammography which was negative for breast cancer. Of note, the test was notable for extremely dense breast tissue, making the study less sensitive as stated in the appeal letter. 

Although the denial letter states that breast ultrasound is only supported if there is an abnormal finding on diagnostic mammography needing further evaluation; the current medical literature does not have the same position. Specifically, supplemental screening with ultrasound of the breast is recommended for high risk individuals (family history of breast cancer) who have dense breast tissue noted on mammogram making it difficult to assess for abnormalities. For this reason, the proposed treatment Ultrasound of the breast; complete study (76641) is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: Intracept Procedure (spine procedure; CPT/CPTS - 22899, and C9752 and/or C9753, Pre-service
The insurer denied the Intracept Procedure (spine procedure; CPT/CPTS - 22899, and C9752 and/or C9753, Pre-service
The denial is upheld. 

The patient is a female with chronic low back pain who continues to have low back pain despite multiple interventions. She has failed medications physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and, epidural steroid injections, facet injections/radiofrequency ablation (RFA).

The requested Intracept procedure is not medically necessary.
The requested health service or procedure is not likely to be more beneficial than standard treatments. 

The patient is a female with chronic low back pain who continues to have low back pain despite multiple interventions. She has failed medications physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and, epidural steroid injections, facet injections/radiofrequency (RFA). 

The Intercept procedure (interosseous basovertebral 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 is typically use in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Modic changes are shown on the attached magnetic resonance image (MRI) report. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intercept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion. 

However, the patient has not failed or attempted sacroiliac (SI) joint interventions, which is common cause of axial low back pain. In situations where all non-invasive options have failed, epidural steroid injections could also be considered, although typically used in patients with radicular symptoms.  Other alternatives, including spinal cord stimulator (SCS), trigger point injections (TPIs) and opiates have been tried and failed.  Chronic opiates are not without risk, and can lead to addiction and overdose. Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed.  Sacroiliac (SI) joint interventions have been shown to be effective in low back pain. In addition, given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically necessary