Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 56-year-old female with a history of muscle and joint pain. The patient was treated 
with several medications to combat the muscle and joint pain and was referred to a chiropractor, 
without significant benefit. The patient underwent a removal of intact breast implant on 4/7/22. 
The Health Insurer has denied the services at issue as not medically necessary for the treatment of 
the patients medical condition. This denial is the subject of this appeal and determination. The 
physician reviewer found that according to Wee and colleagues, while some studies have observed 
overall symptomatic improvement after breast implant removal, There is a lack of studies 
evaluating changes in specific symptoms over time. In this case, the patient has a history of severe 
back, neck, torso, chest, and joint pain due to her breasts. The records provided for review suggest 
that the patients muscle and joint pain were due to the size of the breast implant rather than breast 
implant illness (BII). Loss of range of motion is not associated with BII but is instead most likely 
secondary to a large implant. The patients symptoms overall are secondary to complications of 
implant size and that of a cosmetic procedure. Early capsular contracture would not result in 
limited range of motion and diffuse symptoms. Given these findings, the removal of intact breast 
implant performed on 4/7/22 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 27-year-old male who presented to his provider on 4/20/21. The patient has 
requested reimbursement for rhinoplasty (CPT 30420) performed on 5/05/21. The physician 
reviewer  found  that  Friedman  and  colleagues  stated,  Understanding  nasal  anatomy  and 
physiology  are  the  most  important  points  for  successful  functional  rhinoplasty.  Anatomic 
structures playing major roles in nasal breathing functions include the septum, and internal and 
external nasal valves, so physical examination of these regions is essential. Planning for functional 
rhinoplasty involves the identification of the sites of nasal airway obstruction or old trauma and 
addressing those regions during the operation with a number of different techniques that have 
been described. The submitted documentation fails to demonstrate the medical necessity of 
rhinoplasty (CPT 30420). Findings at surgery described a left laterally displaced nasal bone and 
callus over the left nasal dorsum. A laterally displaced bone would be expected to widen the nasal 
airway and not intrinsically cause nasal airway obstruction. A callus is a bump on the outside of 
the nasal bone that would be cosmetically visible but would not be expected to affect the airway. 
There is no report of external bony nasal deviation causing breathing obstruction. There is no 
photographic documentation of bony nasal deviation. Based on the medical information received 
for review, rhinoplasty (CPT 30420) was not medically necessary for treatment of the patients 
medical condition. The California Reconstructive Surgery Statute requires health insurers to cover 
reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures 
of the body caused by congenital defects, developmental abnormalities, trauma, infection, 
tumors, or disease to do either of the following: (1) To improve function. (2) To create a normal 
appearance, to the extent possible. There is no report or documentation that the appearance of 
the nose was not within the wide range of normal. The services at issue were not documented 
to  improve  function,  and  the  California  Reconstructive  Surgery  Statute  is  not  applicable. 
Therefore, rhinoplasty (CPT 30420) performed on 5/05/21 was not reconstructive in nature.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
The parent of a 16-year-old female enrollee has requested reimbursement for intra-operative 
electromyography (EMG) monitoring and neuromuscular junction testing during spinal surgery 
including anterior cervical procedures on 2/14/22. The Health Insurer has denied this request 
indicating that the services at issue were investigational for the treatment of the enrollee. The 
physician reviewer found that adolescent idiopathic scoliosis is a condition that causes the spine 
to curve in an S or C shape where the etiology is unknown. Symptoms include tilted, uneven 
shoulders, the prominence of the ribs on one side, an uneven waistline, and one hip being higher 
than the other, and may cause back pain and improper growth. In this case, the patient was 
diagnosed with adolescent idiopathic scoliosis and underwent corrective surgery with thorascopic 
anterior spinal tethering. Intraoperative EMG monitoring and neuromuscular junction testing is a 
form of non-invasive intra-operative monitoring (NIOM) that is safe, well-known to improve 
outcomes,  and  standard  clinical  practice  during  spinal  surgery.  Research  demonstrates  that 
intraoperative EMG is necessary to assess the adequacy of nerve root decompression, detect nerve 
root irritation, and improve the reliability of the placement of pedicle screws during spinal surgery. 
Therefore, intra-operative EMG monitoring and neuromuscular junction testing during spinal 
surgery including anterior cervical procedures on 2/14/22 was likely to have been more beneficial 
for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
The parent of a 16-year-old female enrollee has requested reimbursement for intra-operative 
electromyography (EMG) monitoring and neuromuscular junction testing during spinal surgery 
including anterior cervical procedures on 2/14/22. The Health Insurer has denied this request 
indicating that the services at issue were investigational for the treatment of the enrollee. The 
physician  reviewer  found  that  the  patient  had  idiopathic  scoliosis  and  required  surgery. 
Intraoperative neuromonitoring including electroencephalogram (EEG) and EMG are routinely 
used for pediatric spinal surgery to reduce the risk of neurological injury. Sindou and colleagues 
suggest that external anal sphincter EMG recording is useful to avoid sacral root injury during 
spinal  surgery.  Buckwalter  and  colleagues  report  that  out  of  579  surgical  cases,  3.6% 
neuromonitoring changes occurred in 3.6% of the cases, for which no permanent harm was done 
to the patient if corrective actions were performed. Krishnakumar and Srivatsa report that the 
combined  multimodal  intraoperative  monitoring  helps  in  increasing  the  safety  in  scoliosis 
corrective  surgeries  with  a  high  sensitivity  and  specificity.  Therefore,  intra-operative  EMG 
monitoring and neuromuscular junction testing during spinal surgery including anterior cervical 
procedures on 2/14/22 was likely to have been more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3  The parent of a 16-year-old female enrollee has requested reimbursement for intra-operative 
electromyography (EMG) monitoring and neuromuscular junction testing during spinal surgery 
including anterior cervical procedures on 2/14/22. The Health Insurer has denied this request 
indicating that the services at issue were investigational for the treatment of the enrollee.The 
physician reviewer found that while there may be limitations with respect to the degree of 
impairment  measured  during  intraoperative  monitoring,  particularly  with  less  invasive 
methodologies, the aggregate evidence  in current  medical literature uniformly supports this 
adjunctive approach to measuring spinal cord integrity and the potential for spinal cord injury. As 
operator skill and experience may vary widely during this type of surgery, and the potential for 
negative outcomes can be devastating in terms of postoperative morbidity, the service at issue was 
in keeping with best medical practice in the clinical setting of surgical repair of this patients 
scoliosis. Therefore, intra-operative EMG monitoring and neuromuscular junction testing during 
spinal surgery including anterior cervical procedures on 2/14/22 was likely to have been more 
beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 28-year-old male who presented to his provider on 9/2/22. The patient has 
requested reimbursement for magnetic resonance (e.g. proton) imaging, any joint of lower 
extremity, without contrast material, on 9/21/22. The Health insurer has denied this request and 
reported that the services at issue were not medically necessary for the evaluation of this patient.  
The physician reviewer found that the submitted documentation supports the medical necessity 
of a portion of the services at issue. In this case, the patient had left ankle and right knee pain for 
years that did not respond to conservative treatment. Notes dated 9/2/22 reported left posterior 
tibial tendon tenderness and a positive Tinels sign, suggesting impingement. Subsequent MRI 
imaging of the ankle did not show structural issues. The patient reported that the MRIs resulted 
in a diagnosis of Tarsal Tunnel syndrome and referral for EMG. An EMG was conducted by a 
neurologist that confirmed the diagnosis. Notes dated 9/2/22 also reported severe right knee 
medial joint line tenderness and patellofemoral pain. MRI of the right knee revealed a deep root 
tear of the meniscus requiring arthroscopy. While the American College of Radiology (ACR) notes 
that MRI is usually not appropriate in the setting of chronic ankle or knee pain without prior x-
rays, given this patients multi-year history of prolonged and unexplained ankle and knee pain, 
the services at issue were medically indicated. Therefore, magnetic resonance imaging of the 
right knee and the left ankle were medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 52-year-old male who presented to his provider on 12/27/21. The records noted 
sleep apnea diagnosed by sleep study in June 2021 and an apnea-hypopnea index (AHI) of 64. The 
patient has requested authorization and coverage for hypoglossal nerve stimulation. The Health 
Insurer has denied this request and reported that the requested service is not medically necessary 
for the treatment of this patient. This denial is the subject of this appeal and determination. The 
physician reviewer found that the submitted documentation does not support the medical necessity 
of the requested service. The U.S. Food and Drug Administration (FDA) approves the use of the 
Inspire Upper Airway Stimulator for the management of moderate to severe obstructive sleep 
apnea, for patients with AHI greater than 15, aged 18 year and older, with an inability to tolerate 
positive airway pressure (PAP) therapy. The manufacturer of the device, at the time of FDA 
approval, had noted that this device had not been thoroughly tested in individuals with a BMI over 
32 kg/m2. While the FDA approval does not exclude obese patients, current medical literature 
includes only one study evaluating the Inspire implant in obese patients. Huntley and colleagues 
concluded that there was no difference in patients with BMI above or below 32 kg/m2 in response 
to the Inspire implant. However, there is a lack of other studies to support these findings of safety 
in this population. A surgical assessment, performed via a drug induced sleep endoscopy (DISE), 
did confirm anatomic findings which would be favorable and amenable to response from the 
Inspire implant. In this case, while the patient meets a majority of criteria for the requested service, 
including being over age 18, with anatomic findings on DISE amenable to Inspire treatment, an 
inability to tolerate PAP therapy, and a diagnosis of severe obstructive sleep apnea, the patient has 
a BMI of approximately 35 kg/m2. In this clinical setting, given that the patients BMI makes him 
a poor candidate for surgical intervention based on the current available literature, the requested 
service is not medically indicated. Therefore, hypoglossal nerve stimulation is not medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 55-year-old female who presented to the emergency room on 11/10/21 with a  
history  of  a  recent  sinus  infection  treated  with  antibiotics.  The  patient  has  requested 
reimbursement for a hospital stay from 11/10/21 through 11/12/21. The physician reviewer 
found that the submitted documentation supports the medical necessity for the services at issue. 
Acute inpatient care for a patient with suspected meningitis may be appropriate if the patient is 
immunocompromised,has altered mental status, hemodynamic instability, or other factors like 
those present in this case. In this case, patient may have had partially treated meningitis because 
of the antibiotic therapy she had received for sinusitis and, although unlikely because of the CT 
study, she may also have had a small parameningeal focus of infection related to her sinus 
infection. The acute changes in cells, protein, and glucose may imitate the findings in non-
bacterial meningitis in both of these situations. Barring use of polymerase chain reaction (PCR) 
testing or other rapid techniques to make a rapid etiologic diagnosis, the possibility of a partially 
treated  infection  needed  to  be  considered  pending  culture  results. In  this  clinical  setting, 
inpatient care while these issues were evaluated was medically indicated. Therefore, the hospital 
stay from 11/10/21 through 11/12/21 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 54-year-old female who presented to her provider on 10/12/21 for evaluation 
of chronic neck pain. The patient has requested reimbursement for code 01936-QZ 20 units 
anesthesia for percutaneous image guided procedures on the spine and spinal cord performed 
on 11/04/21. The physician reviewer found that the 2019 American Society of Interventional 
Pain Physicians (ASIPP) guidelines on procedural sedation state, Given that patients 
undergoing pain procedures typically are anxious and in pain, mild to moderate sedation is 
acceptable for many patients. The authors went on to further state, "Deeper sedation should 
only be undertaken in the presence of anesthesia providers and for patients who have high 
anxiety, complex pharmacotherapy, or a low pain threshold when undergoing more painful 
interventional pain procedures. In special cases, the risk of patient movement during a 
procedure resulting in potential inadvertent injury may justify a deeper anesthetic state. The 
2016 American Society of Anesthesiologists (ASA) Statement on Anesthetic Care During 
Interventional Pain Procedures for Adults states, Patient anxiety and/or medical comorbidities 
may be an indication for moderate (conscious) sedation or anesthesia care team services. In 
addition, procedures that require the patient to remain motionless for a prolonged period of 
time and/or remain in a painful position may require moderate sedation or anesthesia care 
team services. In this case, the patient was required to undergo a cervical transforaminal 
epidural steroid injection as per recommendations of her neurosurgeon. She has confirmed 
needle phobia and anxiety that required previous anesthetic care during those procedures. 
Furthermore, the cervical transforaminal injection inherently carries a great deal of risk of 
intravascular injection, nerve root injury, seizure, stroke and paralysis. Based on the presence of 
pre-existing anxiety, needle phobia, and danger associated with movement in this procedure, 
the anesthesia used for the procedure was medically necessary. Therefore, code 01936-QZ 20 
units anesthesia for percutaneous image guided procedures on the spine and spinal cord 
performed on 11/04/21 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 24-year-old male who was admitted to the hospital on 5/17/21 with pleuritic 
chest pain and low-grade fever. The patient has requested reimbursement for inpatient hospital 
stay from 5/17/21 to 5/18/21. The physician reviewer found that Myocarditis has been described 
following COVID-19 mRNA vaccinations in young adults, particularly males. The patient had fever 
and a persistent tachycardia in the setting of significant troponin elevation and was appropriately 
hospitalized to monitor for arrhythmias and/or congestive heart failure, as well as heparin drip 
monitoring  which  was  initiated  on  admission.  Hospitalization  can  be  necessary  if  clinical 
instability is noted by virtue of unexplained tachycardia, which could indicate heart failure. The 
medical evidence supports the services at issue in this clinical setting. Therefore, the inpatient 
hospital stay from 5/17/21 to 5/18/21 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the 
ultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at 
issue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. 
The physician reviewer found that American Institute of Ultrasound Medicine (AIUM) notes that 
detailed obstetric ultrasound examination is not intended to be the routine ultrasound examination 
performed for all pregnancies. Rather, the AIUM notes that it is an indication-driven examination 
performed for a known or suspected fetal anatomic abnormality, known fetal growth disorder, 
genetic abnormality, or increased risk for a fetal anatomic or genetic abnormality or placenta 
accreta spectrum. The Society for Maternal-Fetal Medicine (SMFM) notes that the performance 
of the detailed fetal anatomic examination should be rare outside referral practices with special 
expertise in the identification and diagnosis of fetal anomalies. In this case, notes dated 6/2/22 
reported a body mass index of 28 kg/m2, the demise of a dichorionic twin at seven weeks, and the 
finding of a uterine synechia. However, these are not indications that the more detailed fetal 
ultrasound  at  issue  was  likely  to  be  beneficial  than  standard,  routine  ultrasound  screening 
Therefore, ultrasound and reading of the ultrasound on 8/2/22 was not likely to have been more 
beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the 
ultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at 
issue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. 
The  physician  reviewer  found  that  the  American  College  of  Obstetricians  and  Gynecologists 
(ACOG) recommends ultrasound examination for all pregnant patients. The timing and frequency 
depend on the indication for the examination. If a single screening examination is performed, the 
optimal time is at 18 to 20 weeks of gestation. This represents a time when fetal development and 
current ultrasound technology allow for the optimal detection of fetal anomalies. Additional 
important information from this examination includes assessment of the placenta and umbilical 
cord such as the location and placenta accreta spectrum, confirmation of singleton gestation or 
diagnosis of multiple gestation, assessment of cervical length  and screening for short cervical 
length, and assessment of fetal growth. If two screening examinations are performed, the first is 
typically done in the first trimester, either at seven to ten weeks of gestation for reliable assessment 
of pregnancy dating or, in settings of expertise, at 11 to 14 weeks for nuchal translucency 
examination, pregnancy dating, and an early fetal anatomic survey. Increased nuchal translucency 
is a marker for some aneuploidies and genetic syndromes, congenital heart disease, and some 
noncardiac anomalies. In either time period, the first trimester examination also assesses cardiac 
activity, number of fetuses, and chorionicity and amnionicity if there are multiple gestations. The 
second screening examination is performed in the second trimester at 18 to 20 weeks should be 
performed on all pregnant patients for a fetal maternal evaluation of the number of fetuses, 
amniotic/chorionic sacs, survey of intracranial, spinal, and abdominal anatomy, evaluation of a  four-chamber heart view, assessment of the umbilical cord insertion site, assessment of amniotic 
fluid volume, and evaluation of maternal adnexa when visible when appropriate. Wax and 
colleagues note that complete evaluation of the fetus for fetal anatomic or genetic abnormality may 
be indicated in twin pregnancy with fetal loss and retention of one fetus, antepartum condition, or 
complication. In this case, the ultrasound and reading of the ultrasound on 8/2/22 was standard 
therapy. Therefore, ultrasound and reading of the ultrasound on 8/2/22 was likely to have been 
more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 3 
A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the 
ultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at 
issue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. 
The physician reviewer found that the ACOG recommends a detailed anatomy scan for all 
pregnancies, as it has been shown to detect fetal abnormalities and provide the opportunity for 
intervention or clinical decision making. Wax and colleagues note that a detailed fetal anatomic 
examination is indication driven, with indications including, but not limited to, increased risk for 
fetal anatomic or genetic abnormality. In this case, the patient had three risk factors for an abnormal 
pregnancy:  obesity,  twin  demise,  and  uterine  abnormality.  Each  one  of  these  factors  is  an 
indication alone for a detailed fetal anatomic examination.  In this clinical setting, the service at 
issue is standard medical therapy, and there was no other service that would have provided a 
similar benefit.  Therefore, ultrasound and reading of the ultrasound on 8/2/22 was likely to have 
been more beneficial for evaluation of the patients condition than any available standard therapy.