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

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a male. His medical history was negative. His surgical history included finger amputation. He presented to an emergency department with a three-hour history of right-lower-quadrant abdominal pain, vomiting, and diarrhea.

The patient's vitals were temperature 100.1, pulse 83, blood pressure 144/101, respirations 20, and oxygenation 98%. Physical examination demonstrated tenderness-to-palpation of the right-lower-quadrant of the abdomen, and guarding. Moreover, Obturator and Psoas Signs were present. Serum laboratories demonstrated leukocytosis to 14.03. Computed tomography of the abdomen demonstrated acute appendicitis.

The patient was admitted at an acute inpatient level of care with a diagnosis of acute appendicitis. He was made nil per os [NPO], and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. The patient underwent laparoscopic appendectomy. Surgery and recovery were uncomplicated.

The following day, having returned to his baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up. 

No, the admission at an acute inpatient level of care from was not medically necessary.

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al.; Cross et al; Cosse et al.]. In fact, most patients can be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission, even on observational status [Mitchell et al.; Dubois et al.; Cash et al.]. Therefore, for this patient, there was no need for admission at an acute inpatient level of care; he could have been treated at a lower level of care.

According to peer-reviewed medical literature, patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room. Therefore, this patient could have been treated at a lower level of care; he did not require admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

This patient is a male who was found down and admitted with altered mental status and hyperglycemia. In the emergency room, the patient's blood pressure (BP) was 139/100, temperature was 101.3, heart rate was 148, and respiratory rate was 22. The patient's glucose was 545 milligrams per deciliter (mg/dL). Calculated osmolality was 289.  Glycated hemoglobin (A1C) was 16.1%. 

The patient was treated for sepsis possibly due to bullosis diabeticorum. He was treated with Vancomycin and Zosyn. He was given hydralazine for his blood pressure (BP) of 198/107. The patient was treated with subcutaneous insulin. 

Yes, the proposed inpatient stay was medically necessary. 

The requested inpatient stay was medically necessary. This patient was admitted with marked hyperglycemia after being found down. Given his syncope episode, which was complicated by fever at the time of presentation and marked hyperglycemia, he required admission. He also had multiple fluid filled bullae.  He was appropriately initiated on antibiotics for possible sepsis and blood and urine cultures were taken. He had ongoing confusion. He also had persistent hyperglycemia with glucose values up to 422 milligrams per deciliter (mg/dL) and glucose of 376 milligrams per deciliter (mg/dL). Therefore, the requested inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amplified musculoskeletal pain syndrome (AMPS). 
Treatment: Physical therapy services. 

The insurer denied coverage for physical therapy services. 

The denial is overturned. 

This female adolescent patient has been diagnosed with amplified musculoskeletal pain syndrome (AMPS). The patient's treatment included extensive physical therapy. The physical therapy treatment notes provide sufficient objective clinical information to support the medical necessity of the services provided for the treatment dates under review. The physical therapy treatment notes provide evidence of a significant impairment that supports the medical necessity of continuing a structured physical therapy program.  Comparing the physical therapy notes over approximately a 4 month period, there is documented improvement with functional activities such as stair climbing ability, ambulation tolerance and sitting tolerance. Lower extremity motor strength and range of motion have also significantly improved. The physical therapy notes document gradual functional progress and this is considered the standard of care as supported by current peer reviewed medical literature for this patient's clinical scenario. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, physical therapy services provided were medically necessary. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration.  All decisions are evidence-based. 

Based on the above, the medical necessity for the Physical Therapy services provided is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Uterine Fibroids.
Treatment:  Transcervical radiofrequency uterine fibroid ablation.

The insurer denied the transcervical radiofrequency uterine fibroid ablation. The health plan's determination is overturned. 

The patient is a  female who presented with a long history of menorrhagia with bleeding reported as much as 13 days of each month. Her evaluation showed uterine fibroids. She has failed conservative therapies, including hysteroscopy with dilation and curettage. The patient requested a minimally invasive treatment of the fibroids, and objected to the removal of her uterus. She has requested the Transcervical Radiofrequency Uterine Fibroid Ablation.

The Outpatient Surgery Service(s) (transcervical radiofrequency uterine fibroid ablation) is medically necessary for this patient.

Multiple studies show that this is a Food and Drug Administration (FDA) approved procedure and has had its safety and effectiveness established by multiple different investigating groups. The patient meets the established criteria for the procedure. This patient demonstrates classic symptoms of fibroids, including heavy menstrual bleeding. Her bleeding has been severe enough to compromise her daily activities at least 13 of every 24 days - there is no question this premenopausal patient with fibroids needs treatment. She has already failed conservative attempts at treatment, like hysteroscopy. Her history fits the criteria used by both the manufacturer and the studies cited above, indicating she would have an excellent chance of success with this procedure. The requested procedure provides a minimally invasive, safe alternative with a high likelihood (up to 96%) of reducing her symptoms to improve quality of life.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing crown.
Treatment: D2750 White Glass With High Gold Content, Tooth 30.
The insurer denied the D2750 White Glass With High Gold Content, Tooth 30.
The denial is upheld. 

The patient is a female.  This review is for the claim to replace the missing crown on tooth #30.

No, the proposed D2750 White Glass With High Gold Content, Tooth 30 is not medically necessary.

As there is no documentation showing the need for the crown, the crown on tooth #30 is not medically necessary.
Note: There is no x-ray or photo showing a missing crown on tooth #30. The x-rays sent all show a crown already on #30. There is no pre-operative x-ray showing the missing crown.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female who presented to the emergency room with abdominal pain. The patient was thought to have gastritis and was also found to have pneumonia. The patient was admitted to acute in hospital level of care.

No, the proposed inpatient hospital admission was not medically necessary.

The patient had abdominal pain likely due to gastritis. The patient was found to have pneumonia on computed tomography (CT) of the chest and also had elevated white count. However, the patient was hemodynamically stable. The patient was able to take an oral diet and did not require additional oxygen. The patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient stay. 
The insurer denied hospital stay at inpatient level. 
Denial is upheld.

The patient is a male with knee arthritis, polysubstance abuse, previous attempted detox, who presented to the emergency department with chest pain and shortness of breath. The patient intermittent, nonradiating, and sharp pain with associated shortness of breath, nausea, and headache. 

The health plan's denial is upheld. 
The medical team also ordered a computed tomography (CT) scan of the chest, which showed no evidence of focal pulmonary process. Cardiology was asked to evaluate as well.  The following day, the patient feels improved and requested discharge from the hospital. The medical team and the cardiologist recommended a stress test, but he declined. He was evaluated for competency, and determined by psychiatry, to possess the competency for medical decisions. He signed out against medical advice.

Inpatient stay is not medically necessary for this patient. The patient presented to the hospital with chest pain. Cardiac enzymes were negative, and there were no electrocardiogram (EKG) changes. There was no clinical evidence of acute coronary syndrome. A recent echocardiogram revealed normal cardiac function. An acute coronary syndrome was effectively ruled out in the observation timeframe. The medical team recommended a stress test, and the patient declined.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis.

Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient with history of renal calculi.  The patient presented to the Emergency Room (ER) with complaints of severe left flank pain.  The patient's computed tomography (CT) revealed stones within the distal left ureter with moderate left-sided hydroureteronephrosis. In the ER, the patient's triage vitals were: temperature 98.4 and blood pressure 152/90.  The patient's lab showed a creatinine level of 1.73, which was consistent with acute kidney injury (AKI). On exam, the patient had left costovertebral angle tenderness (CVAT).  The patient was given intravenous (IV) fluids and IV morphine in the ER.  The patient's pain improved and he was admitted with the diagnosis of hydronephrosis.  The patient was kept on oral Flomax, and 1 milligram (mg) of intramuscular (IM) Dilaudid for pain control.  The physician and the patient decided that a cystoscopy was not necessary, and decided to try and let the stone pass on its own with medical management.  The patient's condition improved.  

Based on the review of the medical record, the inpatient hospital admission was not medically necessary for this patient. This patient had left hydronephrosis due to presence of stones in the left distal ureter.  The patient elected medical management.  There was no documentation of hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection (UTI), or obstruction in a patient who had only a single kidney or a transplanted kidney.  Per the Milliman Care Guidelines (MCG) Health (24th edition) Renal Colic and Kidney Stones guidelines, the patient fails to meet clinical indications for admission to inpatient care, but does meet guidelines for Observation Care: acute change in kidney function (increase in creatinine). 

The inpatient hospital admission was not considered medically necessary for this patient.

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

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

Diagnosis: Multiple Sclerosis. 
Treatment: Ampyra. 

The insurer denied Ampyra. The health plan's determination is overturned. 

The patient is a woman with multiple sclerosis (MS). She has slow walking speed. Treatment with Ampyra is the subject of this review. 

Ampyra is medically necessary. Ampyra is Food and Drug Administration (FDA) approved to improve walking speed in MS. The patient has impaired gait and no contraindications to the medication. 

The patient has an FDA approved and compendia supported indication which is impaired gait in multiple sclerosis. The drug is intended to improve walking speed for patients with multiple sclerosis. The patient is on a disease modifying therapy. The patient has submitted a timed walking test. The patient has submitted laboratory work showing normal kidney function. The patient does not have a seizure disorder. The patient has no contraindications to treatment with this literature supportive therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psoriatic Arthritis.
Treatment:  Humira.

The insurer denied the Humira.  The denial is overturned. 

The patient is a male with a five year history of psoriasis treated with topical therapy, and a four month history of inflammatory arthritis consistent with psoriatic arthritis. He has been treated with the NSAID (nonsteroidal anti-inflammatory drug) Mobic.

The patient's provider prescribed Humira, and wishes to avoid treatment with DMARDs (disease-modifying anti-rheumatic drugs) such as methotrexate, sulfasalazine, leflunomide or cyclosporine, due to the patient's plan to father additional children with his wife. The Plan acknowledges that methotrexate and sulfasalazine are not indicated under these circumstances but requests an initial trial of leflunomide or cyclosporine. The appeal is for Humira for the treatment of psoriatic arthritis.

Yes, the treatment with Humira is medically necessary.

This patient with psoriasis and active psoriatic arthritis failed treatment with the NSAID (nonsteroidal anti-inflammatory drug) Mobic.  The provider now wishes to treat with the TNF (tumor necrosis factor) inhibitor Humira for severe active psoriatic arthritis, and wishes to avoid alternative Plan-preferred DMARDs (disease-modifying anti-rheumatic drugs) as discussed above, due to family planning concerns.

Humira is FDA (Food and Drug Administration)-approved for the treatment of both psoriasis and psoriatic arthritis, and prior DMARD (disease-modifying anti-rheumatic drug) failure is not required prior to treatment with Humira.  Per a recent UpToDate review, "in patients presenting with severe disease who already have erosive disease and functional limitation, we suggest a tumor necrosis factor (TNF) inhibitor as first-line therapy, rather than a conventional nonbiologic DMARD [(disease-modifying anti-rheumatic drug)] (Grade 2B)."  Furthermore, per published American College of Rheumatology guidelines for the treatment of psoriatic arthritis, for treatment-naive patients with active psoriatic arthritis, treatment with a TNF (tumor necrosis factor) inhibitor biologic is preferred over an oral small molecule (i.e., methotrexate, sulfasalazine, leflunomide, cyclosporine, or apremilast).

The proposed Humira for the treatment of psoriatic arthritis this patient is clinically appropriate, and in accordance with standard of care in the rheumatology community, and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: Xtandi, Pre-service.
The insurer denied the Xtandi, Pre-service.
The denial is upheld. 

The patient is a male with metastatic castrate sensitive prostate cancer.  His provider has requested the use of Xtandi.  The health plan's formulary requires the use of Zytiga (abiraterone) first.

No, the treatment with Xtandi is not medically necessary.

There are formulary options available that will result in equal therapeutic outcomes.

Both Xtandi and Zytiga are valid therapy options for the treatment of metastatic castrate sensitive prostate cancer. Both agents garner a Category 1 level support from the NCCN (National Comprehensive Cancer Network). There is no compelling evidence in the literature to support the use of Xtandi over Zytiga or vice versa. The plan formulary requires the use of Zytiga prior to the use of Xtandi. There is no provided documentation that this patient cannot take Zytiga, such as poorly-controlled diabetes or underlying hepatic dysfunction. There is no medical reason to override the formulary requirements in this case outside of physician preference.

There is no evidence that demonstrates that Xtandi is superior to Zytiga. None of the studies that are cited in the provider's appeal letter compare Zytiga to Xtandi.  The provider's assertion that Xtandi is better is simply preference.  There are no direct comparator studies, and as stated, both have NCCN (National Comprehensive Cancer Network) Category 1 recommendations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic intracranial hypertension.

Treatment: Magnetic resonance imaging (MRI) of the orbit, face and neck with and without contrast (code 70543).

The insurer denied coverage for the magnetic resonance imaging (MRI) of the orbit, face and neck with and without contrast (code 70543).

The denial is overturned. 

This is a female patient who was seen by a Neuro-Ophthalmologist. Visual acuities were 20/20 in both eyes. The patient reported pulsation and whooshing in right ear a few years prior. It was reported that her Magnetic Resonance Venography (MRV) showed venous sinus stenosis. A diagnosis of idiopathic intracranial hypertension was noted and Magnetic Resonance Imaging (MRI) was ordered.

The patient has a suspected diagnosis of idiopathic intracranial hypertension. The diagnosis of idiopathic intracranial hypertension necessitates a normal MRI scan. Thus, the MRI ordered is medically necessary for this patient.

The health care plan did not act reasonably and in the best interest of the patient. The patient has suspected idiopathic intracranial hypertension and part of the workup for this diagnosis is to obtain an MRI to rule out any intraorbital/intracranial pathologies.

MRI of the orbit/face/neck is medically necessary for this patient. Per the clinic note, a diagnosis of idiopathic intracranial hypertension was suspected based on history. Diagnostic criteria for idiopathic intracranial hypertension include a normal MRI scan, normal cerebrospinal fluid (CSF) composition, and elevated lumbar puncture opening pressure. Thus, the MRI is medically necessary to make a diagnosis of idiopathic intracranial hypertension.

The carrier's denial of coverage for the magnetic resonance imaging (MRI) of the orbit, face and neck with and without contrast (code 70543) is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (deep impinging overbite and severe overjet).
Treatment: Orthodontic Treatment.
The insurer denied coverage for the Pre-Service request for Orthodontic Treatment.
The denial is overturned. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite and severe overjet. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD Index is utilized. This index provides 6 specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer's criteria to justify orthodontic care.

The preservice request for orthodontic treatment is considered medically necessary for this patient.

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

The medical necessity for the Pre-Service request for Orthodontic Treatment is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure, Depression, Coronary Artery Disease and Cancer.
Treatment: Increase Consumer Directed Personal Assistance Services 7 Days Per Week 10 Hours Per Day- A Total of 70 Hours Per Week.
The insurer denied the Increase Consumer Directed Personal Assistance Services 7 Days Per Week 10 Hours Per Day- A Total of 70 Hours Per Week.
The denial is upheld. 

The patient is a female with history of Congestive Heart Failure, Depression, Coronary Artery Disease and Cancer. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 70 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

No, the proposed treatment of 70 hours/week Personal Assistance Services is not deemed medically necessary.

This is a female with history of Congestive Heart Failure, Depression, Coronary Artery Disease and Cancer. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 35 hours/week Personal Assistance Services is sufficient to meet the patient's current needs.

Specifically, the assessment revealed that the patient is alert, oriented and able to ambulate and transfer with limited assistance and use of a rolling walker. Furthermore, she is able to feed herself with prepared meals. Lastly, there have been no urgent care or emergency room visits in the past 90 days. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 70 hours/week Personal Assistance Services is not deemed medically necessary.