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

Diagnosis: Central Precocious Puberty (CPP).
Treatment: Fensolvi SGM.
The insurer denied the Fensolvi SGM.
The denial is overturned.

The patient is a female with the diagnosis of CPP (central precocious puberty) based on the appearance of breast at an early age, positive leuprolide test with a pubertal LH (luteinizing hormone) level 8.2 mUI/ml (milli-international units per milliliter), pubertal growth spurt 12 centimeters a year, normal MRI (magnetic resonance imaging) of the brain.

Yes, the requested Fensolvi is medically necessary.

The request for Fensolvi meets the coverage guidelines. After review of the available documentation, the patient has the diagnosis of central precocious puberty (CPP) based on the presence of pubertal changes, and the documented pubertal LH (luteinizing hormone). She has advanced bone age based on the provider reading of the bone maturation. The patient also has accelerated growth. All of these are consistent with the diagnosis of CPP (central precocious puberty).  It is noted that the patient has completed a brain MRI (magnetic resonance imaging), which was negative for abnormalities, which also meets the guidelines.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Ingestion

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is upheld.

This is a child with no significant past medical history. She presented to the emergency room (ER) with complaints of a suspected ingestion of marijuana edibles one hour prior to arrival. The patient was asymptomatic. An electrocardiogram (EKG) and drug testing were normal. The patient was observed for 24 hours as per poison control recommendations. There was no change in baseline activity. She was discharged.

There was no altered mental status, no hemodynamic instability and no need for oxygen or positive pressure ventilation and no need for administration of the antidotes. Also, there was no EKG (electrocardiogram) abnormality nor cardiotoxicity, and no urine drug screen positivity. Also, the monitoring could have been done in observational status. 

Edible cannabis toxicity usually appears in form of transient altered mental status and hence if the mental status were to change, the patient could have been easily transferred to inpatient or step down. Hence no need for inpatient care, patient could have been managed as outpatient or observation

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

The insurer's denial of coverage for the inpatient stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: D6010 implant placement.
Treatment: D6010 implant placement.
The insurer is denied coverage for D6010 implant placement.
The denial is upheld. 
This male patient has no documented history.

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. In regard to 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. Further the documentation provided does not support, justify, or substantiate the requested treatment. 

Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and 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 D6010 implant placement is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Sarcoma 
Treatment: Opdivo (nivolumab) in combination with Yervoy (ipilimumab) 
The insurer denied the  Opdivo (nivolumab) in combination with Yervoy (ipilimumab).
The denial is upheld. 

The patient is a female with stage IV uterine sarcoma with a history of DLBCL (diffuse large B cell lymphoma).  She has received prior therapy with gemcitabine+taxotere.  Her provider has now requested therapy with Yervoy+Opdivo. 

No, the health plan should not cover the Opdivo (nivolumab) in combination with Yervoy (ipilimumab). 

No, the Opdivo (nivolumab) in combination with Yervoy (ipilimumab) is not more beneficial. 

There is no evidence to support the use of Yervoy+Opdivo in the treatment of uterine sarcoma at this time.  This combination has not been shown to be effective therapy for uterine sarcoma.  At this time, the NCCN (National Comprehensive Cancer Network) does not recognize this as valid therapy for uterine sarcoma, and there is no evidence that this is more effective than standard options.  At this time Yervoy+Opdivo has only been studied in small basket sarcoma trials, and these trials have not sufficiently demonstrated safety or efficacy of this therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Sarcoma 
Treatment: Opdivo (nivolumab) in combination with Yervoy (ipilimumab) 
The insurer denied the  Opdivo (nivolumab) in combination with Yervoy (ipilimumab).
The denial is upheld. 

The patient is a female with metastatic uterine sarcoma. She has failed gem/docetaxel and then ifosfomide. She has a history of lymphoma treated in the past with RCHOP (Rituximab, Cyclophosphamide, Hydroxydaunomycin, Oncovin, Prednisone) and in remission. Doxil lowered her EF (ejection fraction). Proposed is ipilimumab and nivolumab. 

No, the health plan should not cover the Opdivo (nivolumab) in combination with Yervoy (ipilimumab). 

There is only preliminary phase II trial evidence, and the responses are poor. In the phase II Alliance A091401 trial reported in The Lancet Oncology, D'Angelo, et al found evidence of activity of nivolumab plus ipilimumab in advanced sarcoma. 

The study comprised two noncomparative randomized phase II trials in which a total of 85 eligible patients from 15 U.S. sites were randomized over a six month timeframe to receive nivolumab at 3 mg/kg (milligrams per kilogram) every 2 weeks or nivolumab at 3 mg/kg plus ipilimumab at 1 mg/kg every 3 weeks for 4 doses, with all patients receiving nivolumab monotherapy at 3 mg/kg every 2 weeks for up to 2 years. 

Patients had to have at least one measurable lesion, evidence of metastatic, locally advanced, or unresectable disease, and had to have received at least one previous line of systemic therapy. The primary endpoint was objective response in the first 76 patients (38 in each group). 

Confirmed objective response was observed in 2 (5% [percent]) of 38 patients in the nivolumab monotherapy group and in 6 (16%) of 38 in the combination group. Responses in the combination group were observed in patients with uterine leiomyosarcoma, nonuterine leiomyosarcoma, myxofibrosarcoma, undifferentiated pleomorphic sarcoma or malignant fibrous histiocytoma, and angiosarcoma. These responses were observed at 1.3 to 4.4 months after the start of treatment and had a median duration of 6.2 months. 

No, Opdivo (nivolumab) in combination with Yervoy (ipilimumab) is not more beneficial. Only phase II trial is available, and the response rate is very low.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Sarcoma 
Treatment: Opdivo (nivolumab) in combination with Yervoy (ipilimumab) 
The insurer denied the Opdivo (nivolumab) in combination with Yervoy (ipilimumab).
The denial is upheld. 

The patient in this case is a woman with metastatic uterine sarcoma, classified as an undifferentiated uterine sarcoma. She has been treated with gemcitabine/docetaxel, Doxil and ifosfamide. Doxil was the most recent treatment. She has progressive metastatic disease. Treatment with ipilimumab and nivolumab has been recommended. 

No, the health plan should not cover the Opdivo (nivolumab) in combination with Yervoy (ipilimumab). 

There is insufficient published evidence indicating that the combination of ipilimumab and nivolumab can improve health outcomes in patients diagnosed with advanced uterine sarcoma. There is no evidence showing that this combination is effective in comparison to standard treatments, and it is not endorsed by NCCN (National Comprehensive Cancer Network) guidelines as a standard treatment option. Given evidence of only limited activity and lack of evidence showing that this treatment can improve health outcomes, this treatment should not be covered. 

No, the Opdivo (nivolumab) in combination with Yervoy (ipilimumab) is not more beneficial. 

There is no evidence showing that this treatment can provide more benefit than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Club Feet and Tight Achilles Tendon. 
Treatment: Inpatient Stay. 

The insurer denied coverage for inpatient stay. 
The denial is upheld. 

This is the case of a patient with a history of bilateral club feet and tight Achilles tendon.  The patient presented to the hospital for lengthening of both Achilles tendons. Post procedure, he was placed on bilateral short leg casts. His pain was controlled with Tylenol, Oxycodone, and Motrin. The patient was evaluated by physical therapy (PT) then discharged to follow up with the Orthopedic surgeon. 

The medical record demonstrates bilateral Achilles tendon lengthening with short leg casts were completed. The records show surgery was approximately one hour. There was limited to no blood loss. The young man was discharged from the PACU [post anesthesia care unit] late afternoon. His post-surgical course was non complicated. The physician record from post operative check noted "DC [discharge] planning". 

His vital signs were stable. There was no evidence of infection. There were no wound problems. He was able to tolerate oral pain medication. 

He did not require treatment for other underlying medical problems. His body mass index (BMI) and weight (270 pounds) were taken into consideration. He was able to full weight bear (FWB) on his casts with durable medical equipment (DME) provided. There were no complications nor extenuating circumstances to substantiate an acute level admission and length of stay. The services could be provided at the lower level of care. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient stay is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bimaxillary protrusion.
Treatment: Braces.
The insurer denied the braces.
The denial is overturned.

The patient is a female with class I malocclusion. She has bimaxillary protrusion, where her front teeth are too pronounced forwards. She has crossbite of the lower first premolars. The request is for braces. The appeal is due to low Salzmann index score.

Yes, the braces are medically necessary.
The patient's upper and lower front teeth stick out too far and are too prominent. There is a lack of "incisal guidance." This means that when the patient moves her lower jaw forward, instead of her lower teeth gliding along the backs of her upper front teeth, her teeth will grind together in a traumatic way. This needs to be corrected with the medically necessary orthodontic treatment. If this is not corrected, trauma and fractures will most probably occur to her teeth.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chest pain
Treatment: External Counter Pulsation Treatment (EECP). 
The insurer denied External Counter Pulsation Treatment (EECP). The health plan's determination is upheld. 

The patient is a female who had COVID. She was having chest pain 3 times per week. There was fatigue and brain fog. EECP (External Counter Pulsation Treatments) for the fatigue and chest pain is under review.

The External Counter Pulsation Treatments is not likely to be beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
EECP is a Counterpulsation treatment applied to the lower extremities. In the past it had been utilized, under certain circumstances, for those with angina. In this setting, there was no definitive evidence that it improves cardiac outcomes. Recently, the same treatment has been applied to those with post-COVID symptoms such as fatigue. However, there is only anecdotal subjective evidence that it may improve some post-COVID symptoms. Overall, there is no definitive evidence that it is established as standard of care towards improved cardiac or overall post-COVID outcomes. Therefore, it is not indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chest pain
Treatment: External Counter Pulsation Treatment (EECP). 
The insurer denied External Counter Pulsation Treatment (EECP). The health plan's determination is upheld. 

The patient is a woman a diagnosis of post-acute sequelae of SARS Covid infection (PASC). She has continued symptoms of chest pain, palpitations, dyspnea, fatigue, insomnia, nausea, vomiting and cognitive changes. Coverage for enhanced external Counterpulsation (EECP) is at issue.

External Counter Pulsation Treatments are not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has multiple symptoms that have been attributed to post-acute sequelae of SARS CoV-2 infection (PASC) or "long COVID". PASC encompasses myriad symptoms including chest pain, palpitations, fatigue, orthostatic intolerance and cognitive dysfunction that can last for weeks or longer. There are reports of symptom improvement in some patients with physical and occupational therapy. Others have suggested treatment of autonomic symptoms with fludrocortisone, midodrine and salt and fluid loading may be of benefit. However, to date, no particular treatment, pharmacologic or nonpharmacologic, has been shown to be effective in controlled or large-scale cohort studies.
The treatment proposed in this case is enhanced external Counterpulsation, or EECP, a noninvasive therapy that intermittently compresses the lower extremity vessels. It is Food and Drug Administration (FDA) approved to reduce the intensity and frequency of angina-related chest pain. There are two case reports in the medical literature, each involving a single patient, that report symptomatic improvement with EECP in patients with PASC. However, the information available to date is insufficient to determine that this service, in this instance, is likely to be effective in this particular patient or likely to be more beneficial than any other treatment in ameliorating her symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac
Diagnostic testing

Diagnosis: Chest pain
Treatment: External Counter Pulsation Treatment (EECP). 
The insurer denied External Counter Pulsation Treatment (EECP). The health plan's determination is upheld. 

The patient is a woman with autoimmune arthritis and COVID 19 infection. She had chest pressure, with episodes occurring almost daily, and fatigue. She was treated with Provigil. External Counter Pulsation Treatment (EECP) was ordered and is the subject of this review. 

External Counterpulsation Treatments are not likely to be more beneficial than standard treatments for this patient with post-COVID symptoms of fatigue and chest pain. It is Food and Drug Administration (FDA) approved as a class IIB (divergence of opinion, but weight of the evidence not in favor of treatment) for refractory angina. While there is a case report (3) using EECP for post-COVID sequelae, it would be considered experimental or investigational for this indication. Therefore, it is not indicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot Pain/ Flat Feet (plantar fasciitis). 
Treatment: Durable Medical Equipment (custom shoe inserts). 

The insurer denied the Durable Medical Equipment (custom shoe inserts).  The denial is overturned. 

The patient is a male diabetic. He was going to his podiatrist for nail care. He was having pain in his shoe for more than a year. He had worn orthotics, which had worn out. He used over-the-counter orthotics with no improvement. The patient also was diagnosed with cavus foot, as well as plantar fasciitis. 

Yes, the custom shoe inserts are medically necessary. 

Custom inserts are typically utilized when conservative over-the-counter inserts have failed and when patients have diabetes. Diabetic patients are at risk for foot problems that can lead to amputation. As they often cannot determine pain level due to their neuropathy, this may come on gradually. Foot deformities are often corrected aggressively in diabetics. This includes the use of custom molded orthotics. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The patient is diabetic and suffers from plantar fasciitis as well as cavus foot that is painful. The patient has tried and failed over-the-counter inserts without any improvement. Custom inserts in this case would be medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Localized Skin Infection with Swelling and Redness (Eczema)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male admitted to the hospital with fever and worsening rash, with facial and eye swelling.  He was started on antibiotics with improvement during his hospital course.  The hospital admission was deemed not medically necessary as the patient had stable vital signs, and there was no documentation of failure to improve after observation, there were no concerning labs, and the denial states that the patient did not have "swelling around the eye that did not get better after treatment."

Yes, the proposed inpatient admission was medically necessary.
The patient did have swelling around the eye that did not get better after treatment.  He was diagnosed with a fungal infection about a week prior and placed on clotrimazole cream, but per the documentation, the left eye swelling got worse.  He also had documented fever. Given the severity of the eye and skin presentation, the admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Neck and back pain
Treatment: Chiropractic Services (CPT Code: 98943, 97140.59, 97530, 97012)
The insurer denied the Chiropractic Services (CPT Code: 98943, 97140.59, 97530, 97012).
The denial is partially overturned.

The patient is a female. According to the documentation, the patient presented for chiropractic evaluation and treatment. The attending practitioner noted that the patient had a history of back and neck complaints with no real etiology noted.

Upon evaluation the attending practitioner diagnosed the patient with the following: pain in the thoracic spine, muscle spasm, subluxation to the thoracic spine, pain in the right shoulder, insomnia, depression and anxiety. A course of treatment was implemented to the patient by the attending chiropractic practitioner, which consisted of modalities including traction, manual therapeutic techniques, rehabilitative techniques in addition to manual manipulative techniques to the spine as well as extremity.

The patient underwent a follow-up treatment with the attending chiropractic practitioner, and it was proposed that treatment would be warranted.

Yes, in part. The requested Chiropractic Services (98943, 97140.59, 97530, 97012)  were medically necessary, in part.
Specifically, the 97140.59 manual therapeutic techniques utilized by the attending chiropractic practitioner would not be considered reasonable or necessary concerning this case. Such procedures performed concurrently as the manual manipulation (i.e., 98941) as provided by the attending practitioner to the patient in the same or similar region being manipulated would not conform to proper treatment and therefore not supported through the records submitted.

However, all other codes performed to the patient by the attending practitioner from consisting of 98943, manipulation of extremity joint, 97530, kinetic activities as well as 97012, traction would be considered reasonable, necessary and supported through the records submitted concerning this case.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
As explained through the rationale to question number 2, all codes rejected by the health plan other than 97140.59 would be considered reasonable, necessary and supported concerning this particular case. To deny codes 98943, 97530 and 97012 would not be in the patient's best interest.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.	
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

The patient has a past medical history of gastroesophageal reflux disease, immune compromise with medication non-compliance.  The patient was sent to the emergency department from presurgical testing for abnormal lab studies.  She was status post presurgical testing.  She was scheduled for eye surgery. She denied dizziness, chest pain, dyspnea.  The patient reported frequently taking Aleve/Advil for recent ear pain.  She denied any rectal bleeding, melena or hematemesis. The patient's blood pressure was 176/72.  Exam in emergency department (ED) noted brown stool guaiac positive. Exam otherwise unremarkable.  Labs showed a potassium (K+ [potassium]) of 3.1, creatinine of 0.93, blood urea nitrogen (BUN) 18, hematocrit (Hct) 23. Computed tomography (CT) of abdomen/pelvis revealed no acute findings. The patient was transfused with 2 units of blood.  The Hct was 37.   The patient was given oral potassium and requested intravenous potassium as she did not like the taste.  The patient was admitted to the medical/surgical unit for evaluation of anemia.  The patient underwent a gastrointestinal evaluation and chose to leave Against Medical Advice.

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

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

The patient was found to be anemic and mildly hypokalemic during presurgical testing for eye surgery. She was hemodynamically stable with no evidence of active bleeding.  She had no symptoms related to the anemia or hypokalemia. Transfusion could have been done during a period of observation, and in fact by the morning her Hct was 37.  A potassium (K+) of 3.1 does not require acute intervention and is managed as an outpatient (OP)

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.