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

Diagnosis: Ears/Nose/Throat. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Dupixent. 
The health plan's determination is upheld. 

The patient is a female with request for Dupixent for rhinosinusitis with nasal polyps. She has tried fluticasone and other nasal sprays not at maximal doses, and with nasal bleeds. She also has asthma and is on Singulair. There are no claims for Breo. The subject under review is the medical necessity for Dupixent. 

The requested treatment with Dupixent is not medically necessary. 

Dupixent is Food and Drug Administration (FDA) approved for CRS (chronic rhinosinusitis) with NP (nasal polyps). The current standard of care for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) includes the use of systemic corticosteroids as needed for acute symptom management and maintenance therapy with intranasal corticosteroids. Sinus surgery to remove nasal polyps is another treatment option that can be considered when pharmacologic therapies have failed. Relapse after surgery is common, however, and revision surgery is often required. In the trials for Dupixent that led to its approval for CRSwNP, the co-primary efficacy endpoints were the change from baseline in the nasal polyps score (NPS) and the nasal congestion/obstruction (NC) score. In this case, the patient has not tried and failed first line therapies for CRS with NP. Thus, Dupixent is not medically necessary for this patient. There are no head to head studies to show that Dupixent is more effective or has less side effects than the plan alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/prescription Drugs. 
The insurer denied Lidocaine 5% external (Ex) Patch. 
The denial is upheld. 

This patient is a female. A left knee x-ray revealed mild medial joint space, mild medial and patellofemoral periarticular spurring, and medial and lateral meniscal chondrocalcinosis. A patient instruction form recommends scheduling an magnetic resonance imaging (MRI) of the left tibia/fibula and knee and using the lidocaine patch as prescribed. A left knee MRI radiology report, reveals a new radial tear of the posterior root of the medial meniscus with extruded body, mild to moderate medial, mild lateral, and mild to moderate patellofemoral arthrosis, and small effusion. An undated letter of medical necessity from the physician indicates the patient was seen in their office for a diagnosis of left knee pain. The patient has been on lidocaine 5% patch before and has seen improvement on pain. The provider states the patient claimed they were trying the 4% lidocaine appointment without benefits. The provider goes on to note the patient states that they tried physical therapy, but after a few sessions, their condition and pain only got worse. The patient occasionally does exercises at home. They also use cold compresses, infrared heat, and transcutaneous electrical nerve stimulation (TENS) unit, but the condition does not improve. It is noted that the patient reports that with severe pain, they cannot do physical therapy at all except for applying cold compresses.
At issue is the medical necessity of Lidocaine 5% external (Ex) Patch.

The health plan's determination to deny coverage for lack of medical necessity is upheld in whole.

The requested health service/treatment of Lidocaine 5% external (Ex) Patch is not medically necessary for this patient.

The provided documentation indicates the patient has tried lidocaine 5% patches for the treatment of chronic knee pain. Lidocaine patches are not United States Food and Drug Administration (FDA) approved for this condition, and there is no medical literature supporting this off-label use for the treatment of chronic knee pain. Therefore, the health plan, in its determination of medical necessity, acted reasonably with sound medical judgment. There is no peer reviewed medical literature to support the use of lidocaine 5% external patch for the treatment of knee pain.
Therefore, the requested treatment of lidocaine 5% external patch is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paroxysmal atrial fibrillation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a woman that presented to the hospital for an elective catheter ablation of paroxysmal atrial fibrillation. Her relevant past medical history included hypertension, diabetes mellitus, chronic kidney disease, hypothyroidism and breast cancer status post left lumpectomy.

The patient underwent left atrial catheter ablation with pulmonary vein isolation under general anesthesia. Her intraoperative course was complicated by a traumatic intubation. Her post-operative course was characterized by hemoptysis, odynophagia, dysphasia and dysphonia. She required evaluation by an ENT (otolaryngology) specialist, and laryngoscopy was performed. She was found to have erythema and bruising of the bilateral oropharyngeal walls. ENT (otolaryngology) recommendations were for close monitoring of respiratory status and soft food intake.

Yes, the Inpatient admission was medically necessary.
This patient underwent elective left atrial catheter ablation for symptomatic atrial fibrillation. The procedure was complicated by traumatic intubation that resulted in pharyngeal bleeding, inability to speak and inability to swallow without pain. The patient required evaluation by an ENT (otolaryngology) specialist and recommendations were for additional monitoring to ensure that pharyngeal bruising did not result in airway obstruction.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient presented to the hospital for an elective electrophysiologic study and ablation of atrial fibrillation. According to hospital records, the ablation was complicated by traumatic intubation resulting in oropharyngeal bruising. Observation following ablation was significant for hemoptysis and painful swallowing. The patient required ENT (otolaryngology) evaluation. In this case, pharyngeal trauma was significant and required additional evaluation and treatment. The patient required a higher level of care.

In two multicenter registry studies looking at healthcare utilization after EP (electrophysiology) study catheter ablation, 20% of patients undergoing ablation were hospitalized for more than a single day (Reference 1,2) Hosseini noted that patients undergoing complex ablation such as ablation atrial fibrillation were more likely to have complications requiring hospital admission with an increased length of stay. (Reference 3)

In conclusion, acute inpatient admission was medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes and end stage renal disease
Treatment: Surgical procedure on the kidney 
The insurer denied surgical procedure on the kidney. 
The determination is overturned.


The patient has type 2 insulin-dependent diabetes mellitus (IDDM) and end stage renal disease (ESRD), dialysis dependent (well-tolerated peritoneal dialysis) who has been evaluated and deemed a good candidate for combined (simultaneous) kidney pancreas transplant (SPK). The health plan denied a surgical procedure on the kidney as not medically necessary and that is under review for medical necessity.

Yes. The requested procedure is medically necessary based on the information provided.
SPK in a a type 2 diabetic with renal failure is a reasonable treatment option and can be considered standard of care. Large database analyses reveal comparable outcomes to SPK for type 1 diabetes mellitus (DM) / end stage renal disease (ESRD). Moreover, the kidney transplant outcome is superior in a diabetic with SPK over a diabetic with kidney transplant alone. There is a negative urine drug screen which should be sufficient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes and end stage renal disease
Treatment: Surgical procedure on the kidney 
The insurer denied surgical procedure on the kidney. 
The determination is overturned.


The patient has type 2 insulin-dependent diabetes mellitus (IDDM) and end stage renal disease (ESRD), dialysis dependent (well-tolerated peritoneal dialysis) who has been evaluated and deemed a good candidate for combined (simultaneous) kidney pancreas transplant (SPK). The health plan denied a surgical procedure on the kidney as not medically necessary and that is under review for medical necessity.

Yes. The requested procedure is medically necessary based on the information provided.
SPK in a type 2 diabetic with renal failure is a reasonable treatment option and can be considered standard of care. Large database analyses reveal comparable outcomes to SPK for type 1 diabetes mellitus (DM) / end stage renal disease (ESRD). Moreover, the kidney transplant outcome is superior in a diabetic with SPK over a diabetic with kidney transplant alone. There is a negative urine drug screen from June 2021, which should be sufficient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Xeljanz. 
The denial is upheld.

The patient is a male with ulcerative colitis (pancolitis), psoriasis, and iron-deficiency anemia. He has failed mesalamine, Uceris foam, Remicade, and Entyvio. He has had improvement on Xeljanz 10 milligrams (mg) twice daily. Colonoscopy showed no disease activity. The subject under review is the medical necessity of Xeljanz for the treatment of Ulcerative Colitis.

the request for Xeljanz 10 mg is not supported as medically necessary by the submitted documentation in the case. Xeljanz has proven effective in a double-blind, placebo-controlled trial of patients with moderate-severe ulcerative colitis [1-5]. American Gastroenterological Association guidelines for the treatment of ulcerative colitis recommend Xeljanz to attain remission after failure of anti-tumor necrosis factor agents [6]. However, the requested dose is not supported.

According to the Food and Drug Administration (FDA)-approved prescribing information for Xeljanz, the dose of Xeljanz 10 mg twice daily is supported for 8 weeks; if needed, Xeljanz 10 mg twice daily or Xeljanz XR 22 mg once daily is supported for a maximum of 16 weeks, followed by maintenance with Xeljanz 5 mg twice daily or Xeljanz XR 11 mg once daily; for patients with loss of response during maintenance treatment, Xeljanz 10 mg twice daily or Xeljanz XR 22 mg once daily may be considered and limited to the shortest duration, with careful consideration of the benefits and risks for the individual patient [5]. Per the FDA-approved prescribing information, "For patients with loss of response during maintenance treatment, Xeljanz 10 mg twice daily or Xeljanz XR 22 mg once daily may be considered and limited to the shortest duration, with careful consideration of the benefits and risks for the individual patient. Use the lowest effective dose needed to maintain response"; Xeljanz has adverse effects, and use of the minimal effective dose is advisable [5]. In this case, the failure of the standard dose of 5 mg twice daily or 11 mg daily (of Xeljanz XR) is not documented. For this reason, the request to continue Xeljanz 10 mg is not supported.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with history of asthma with cough and wheezing who was sent from urgent care to the emergency room for asthma exacerbation. In the emergency room, the patient was tachycardiac and tachypnic. The patient received intravenous (IV) steroids and albuterol nebs and was admitted to acute in hospital level of care. The patient was continued on intravenous steroids and albuterol during hospitalization. The patient left the hospital the next day. The acute in-hospital level of care was denied due to lack of medical necessity. This denial is being appealed.

No, the proposed treatment, inpatient hospital admission, was not medically necessary.
This patient had an asthma exacerbation and received treatment in the emergency room. At the time of admission, the patient was hemodynamically stable. The patient was not in any distress. The patient was not in supplemental oxygen. The patient's asthma exacerbation symptoms had improved significantly due to emergency room treatment. The acute in-hospital admission was not medically necessary as the patient could have been safely and effectively be treated at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental or Orthodontic treatment and monthly visits. 
The insurer denied orthodontic treatment and monthly visits. 
The determination is overturned.

The patient is a male presenting with a skeletal Class I malocclusion and significant crowding. He has an anterior open bite. He is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to address the crowding and open bite, but the treatment was denied due to lack of medical necessity.

The health plan's determination is overturned.

Orthodontic treatment is medically necessary for this patient due to the fact that this is not something that will self-correct without orthodontic intervention. Anterior open bite patients are among the most difficult patients to treat.1 One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.2 Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite.3 This patient is treatment planned for extractions, which is less expensive and less invasive than orthognathic surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection (UTI) and hydronephrosis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient was admitted for urinary tract infection (UTI) and hydronephrosis secondary to nephrolithiasis, she underwent cystoscopy with stone removal and discharged the next day. 

The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain, she was able to tolerate oral diet and did not require total parenteral nutrition and her condition responded to intravenous fluid and antibiotics in 24 hours. 

Based on the patient's presenting signs/symptoms and the predictability of something adverse that will occur to the patient based on these presenting signs/symptoms, her level of acuity did not meet any guideline requirement for inpatient hospitalization.  When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done in the ER (emergency room) and the availability of any additional diagnostic testing as an outpatient, there was no clinical criteria for inpatient level of care.  Overall, the patient's condition could have been managed safely on an observation basis. Nothing was done for the patient during her inpatient level of care that could not have been or had not already been managed on an observation level of care. Based on all these reasons, she had no requirements for inpatient level of care. 

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

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

Diagnosis: Coronary artery disease (CAD), osteoarthritis (OA), cataracts, gastroesophageal reflux disease (GERD). 

Treatment: PCW (Personal Care Worker) services two 12 hours (split shift) per day, 7 days per week. 

The insurer denied coverage for PCW services two 12 hours (split shift) per day, 7 days per week. 

The denial is overturned. 

This patient with chronic medical problems including coronary artery disease, osteoarthritis and cataracts.  She lives alone.  PCW services were increased to 24 hour live in per day, 7 days per week. 

According to the Uniform Assessment System (UAS) report, the patient is totally dependent for activities of daily living including bathing, dressing, personal hygiene and toilet use.  She is incontinent of bowel and bladder.  Cognition is "severely impaired" and declining.  She is totally dependent for bed mobility and is non-ambulatory.  The combination of her severe cognitive deficits, functional incapacity, progressive decline and necessity for 24 hour supervision support the requested PCW services of two 12 hours (split shift) per day, 7 days per week, to allow the patient to continue living safely at home.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, the requested worker (PCW) services two 12 hours (split shift) per day, 7 days per week, is considered medically necessary for this patient.  

The insurer's denial of coverage for personal care worker (PCW) services two 12 hours (split shift) per day, 7 days per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis. 
Treatment: Inpatient Admission. 

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

The patient is a female who was seen at the hospital for new onset RLQ (right lower quadrant) pain. Patient was found to have early acute appendicitis. WBC (white blood cells) 6. No guarding on exam with only RLQ (right lower quadrant pain). Patient was taken to the OR (operating room) and laparoscopic appendectomy. Patient was discharged the same day. She did have a history ovarian cyst that was going to be removed on an elective basis. 

No, the inpatient hospital admission is not medically necessary. 
The surgical treatment of the early acute appendicitis was appropriate. However, she could have been admitted to an observation status given no evidence of sepsis, perforation, or abscess. 

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

This patient did not demonstrate any evidence of sepsis, abscess, or perforation on initial CT (computed tomography) scan. There are studies demonstrating that acute nonperforated appendicitis can be treated at the outpatient level.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Diarrhea.
Treatment: Polymerase Chain Reaction Gastrointestinal Test (87507).
The insurer denied the Polymerase Chain Reaction Gastrointestinal Test (87507).
The denial is upheld.

The patient is a male who has a history of C difficile (Clostridium difficile) diarrhea and was status post treatment. As the patient continued to evidence significant diarrhea and other gastrointestinal symptoms, his provider ordered a PCR (polymerase chain reaction) test. The plan declined coverage, as it deems this testing to be experimental or investigational.

No, the health plan should not cover the Polymerase Chain Reaction Gastrointestinal Test (87507).
Standard testing for C difficile (Clostridium difficile), including antigen or toxin, would be appropriate and sufficient to guide therapy for this patient. There is no cogent medical literature to mandate the use of PCR (polymerase chain reaction) testing when standard testing is sufficient.

No, the Polymerase Chain Reaction Gastrointestinal Test (87507) is not more beneficial.
The use of a PCR (polymerase chain reaction) test for C diff (Clostridium difficile) is not more beneficial than standard testing for C difficile (Clostridium difficile) infections.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Diarrhea.
Treatment: Polymerase Chain Reaction Gastrointestinal Test (87507).
The insurer denied the Polymerase Chain Reaction Gastrointestinal Test (87507).
The denial is upheld.

The patient is a male with a prior history of C. difficile (Clostridium difficile) colitis presented with fecal leakage and chronic diarrhea. The patient's provider ordered gastrointestinal pathogen panel by PCR (polymerase chain reaction).

No, the health plan should not cover the Polymerase Chain Reaction Gastrointestinal Test (87507).
The patient has recurrent diarrhea. There is no evidence that he is immunocompromised, has severe diarrhea with high fevers, bleeding or hemodynamic instability, or has travel related diarrhea. There is no medical literature to support that gastrointestinal pathogen panel is more effective in the diagnosis of diarrhea, as compared to conventional stool studies, as well as a C difficile (Clostridium difficile) PCR (polymerase chain reaction) test. Therefore, the health plan should not cover the Polymerase Chain Reaction Gastrointestinal Test (87507).

No, the Polymerase Chain Reaction Gastrointestinal Test (87507) is not more beneficial.
There is no medical literature to support that gastrointestinal pathogen panel is more effective in the diagnosis of diarrhea, as compared to conventional stool studies, as well as a C difficile (Clostridium difficile) PCR (polymerase chain reaction) test. Therefore, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease