Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Fibroadenomatoid

Treatment: 77049 magnetic resonance imaging (MRI) of the breast - bilateral, A9585-JW x 49 (injection, gadobutrol - drug amount discarded/not administered to any patient), and A9585 x 51 

The insurer denied coverage for 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast.

The denial is overturned.

According to the medical records, this is a female with a history of Hodgkins lymphoma treated with radiotherapy directed to her thoracic region. Request is for retrospective approval of 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

According to Mulder, R. L., et al, "Conclusion: The newly identified evidence prompted significant change to the recommendations formulated in 2013 related to moderate-dose chest radiation and anthracycline exposure as well as breast cancer surveillance modality."

Lastly Monticciolo, D. L., et al state, "Breast MRI is also recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed [later in life]. Others with histories of breast cancer and those with atypia at biopsy should consider additional surveillance with MRI, especially if other risk factors are present. Ultrasound can be considered for those who qualify for but cannot undergo MRI. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk at [an early age], so that those at higher risk can be identified and can benefit from supplemental screening."      

Codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast do have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is a good candidate for codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast.     

Codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast are the best available treatment for this patient at this time.  

The adverse risks are not increased over standard treatment/services. MRI is likely to be more beneficial than any other testing.

The MRI is standard of care in the patient's situation given that she has a > 20% [percent] risk for breast cancer secondary to her history of therapeutic radiation to her thoracic for Hodgkins lymphoma. MRI in her setting is supported by numerous high quality prospective clinical outcomes published in the medical literature as well as expert consensus national guidelines.                                                    
      
The carrier's denial of codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Fibroadenomatoid

Treatment: 77049 magnetic resonance imaging (MRI) of the breast - bilateral, A9585-JW x 49 (injection, gadobutrol - drug amount discarded/not administered to any patient), and A9585 x 51 

The insurer denied coverage for 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast.

The denial is overturned.

The patient is a female with a history of Non-Hodgkin's lymphoma, thyroid nodules, and osteopenia. She had a telephone encounter with the General Surgeon. The physician told the patient about an increased area of enhancement that is suspicious on the right breast. Magnetic resonance imaging (MRI) with a biopsy was recommended. The procedure was performed. The MRI showed a right breast 2.9 centimeter (cm) clumped non-mass enhancement with an increase in size that was suspicious. The biopsy revealed findings that were consistent with a prior biopsy. 

Second cancer is the leading cause of death in long-term survivors of Hodgkin disease (HD), with exceptionally high risks of breast cancer among women treated at a young age. Women treated with chest radiation have a substantially elevated risk for breast cancer at a young age, which does not seem to plateau. In this high-risk population, there is a benefit associated with early detection. According to the American Cancer Society screening recommendations, women who are at high risk for breast cancer based on certain factors should get a breast MRI and a mammogram every year. This includes women who had radiation therapy to the chest when they younger.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is a good candidate for codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast.

Codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast is the best available treatment for this patient at this time.

The adverse risks do not increase over standard treatment/services.

The requested service is likely to be more beneficial than any of the standard procedures for this patient.

The carrier's denial of codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Premenstrual dysphoric disorder (PMDD), anxiety disorder, depression
Treatment: Fluoxetine 
The insurer denied Fluoxetine. 
The denial is upheld.

The patient is a female who had gone off her medications for a couple of months and was under care for mood disorder and controlled substances. She was seen and noted to be on Fluoxetine 20 milligrams (mg) and bupropion 300 mg extended release (XL) for control of premenstrual dysphoric disorder (PMDD). She was also on Adderall 20 mg in the morning and 10 mg in the evening for attention deficit hyperactivity disorder (ADHD). The patient was also on Spironolactone under the care of dermatology. The patient was up to date on pap screening and pelvic exam. She had a normal exam noted. She was noted to have anxiety disorder and was to continue on fluoxetine for this and PMDD. She was also noted to be stable on this medication. Her history of depression dated back to 14 years ago in the historical notes and she was stable on Fluoxetine. Wellbutrin was added. This patient is under consideration for Fluoxetine for the diagnosis for PMDD. The patient is reported to have been on Fluoxetine 20 mg with good response to therapy in a letter.

Based upon a review of the medical records, the formulary drugs that are offered and the current medical indications for the use of Fluoxetine finds that the generics for Sarafem, paroxetine hydrochloride (HCL) extended release or sertraline would not be less effective or as effective as the non-formulary drug request for Fluoxetine in this case. There are no supported adverse events that would be associated with the use of the alternative options of proposed formulary drugs in this case. In this case, the patient has not tried or failed any of these appropriate preferred formulary alternatives for management of PMDD. In this case, there is no evidence that the patient cannot be switched to a formulary drug, has any intolerance or inadequate response or contraindication to the alternatives. There is Food and Drug Administration (FDA) approval of the alternative agent for therapy in this case. There is no evidence that the patient has tried and failed three formulary alternatives in this case.

Evidence from trials on PMDD reveals that selective serotonin reuptake inhibitor (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are effective within the first menstrual cycle and also are effective with intermittent luteal-phase treatment. In this case, the preferred formulary alternatives are SSRI or SNRI options for treatment of the patient for this condition. Based upon the recommendations of American College of Obstetricians and Gynecologists (ACOG) and multiple peer reviewed prospective studies is SSRI and SNRI options, the preferred formulary alternatives would not have been ineffective or less effective than the non-formulary option of Fluoxetine.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System - Asthma. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned in whole. 

This is the case of a female who presented to the emergency department (ED) with cough, congestion, rhinorrhea, and shortness of breath. Symptoms were worsening for 2 days prior to presentation despite patient's mother giving albuterol. There were no fevers, vomiting, diarrhea, or chest pain. Social history notable that patient and mother are currently residing in a shelter.
ED vitals temperature (T) 37 Celsius (C), heart rate (HR) 123-138, respiratory rate (RR) 32-34, blood pressure (BP) 103/66, oxygen (O2) sat 90% on room air. Exam was notable for tachypnea with decreased breath sounds, wheezes, and rhonchi. Albuterol given without obvious effect. The patient was started on 2 liters (L) oxygen (O2). Flu, respiratory syncytial virus (RSV), and Coronavirus disease 2019 (COVID) tests were negative.
Chest x-ray showed left basilar opacity consistent with (c/w) probable atelectasis. The patient was given Duonebs (albuterol/ipratropium) and prednisolone. The patient was admitted to the hospital for further management.
At issue is whether the medical necessity for the inpatient stay.

The requested inpatient stay was considered medically necessary for this patient. This previously healthy patient presented with acute wheezing and respiratory distress. She was treated for acute asthma exacerbation and required initiation of oxygen therapy for oxygen saturation levels that dropped to 90%. Additional complexity to this patient's care includes housing instability with current shelter placement for the family, thus creating uncertainty of outpatient follow-up.
This patient required treatment for acute asthma exacerbation, including supplemental oxygen for hypoxemia. Her medical status improved quickly upon admission to enable progression to discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. The denial is overturned. 

The patient is a male with eczema and allergies who presented with an acute asthma exacerbation. He was well until 2 days prior to presentation when he developed chest pain, dyspnea, cough, and wheeze. These symptoms persisted and he awoke with a coughing fit and was unable to catch his breath. He tried albuterol at home with limited response, and therefore his mother called for emergency services. He was given one dose of albuterol in transit in the ambulance and was brought to the emergency department for care. 

In the emergency department, he was found to be wheezing with decreased breath sounds at the lung bases and belly breathing. A chest X-ray was obtained, and he received oral corticosteroids, 3 albuterol/Atrovent nebulized treatments, and magnesium sulfate as well as a normal saline bolus. After those treatments he continued to require albuterol more frequently than every 2 hours, and therefore he was admitted to the hospital for further care for status asthmaticus. 

In the hospital he was placed on an asthma treatment pathway and received albuterol treatments and corticosteroids. He improved with this treatment, and was able to space to every 4 hour albuterol treatments. He was felt to be stable for discharge to home with continued treatment and follow up as an outpatient. 

The inpatient hospitalization is under review for medical necessity. 

The health plan's determination is overturned. 

The requested health service/treatment of inpatient stay was medically necessary for this patient. 

This is a patient who presented in status asthmaticus. He received albuterol at home with limited response and received appropriate and aggressive treatment in the emergency department including bronchodilators, corticosteroids, and magnesium. However, he continued to require frequent breathing treatments (more frequent than every 2 hours) and therefore required hospital admission for ongoing treatment and close monitoring. 
 
Patients with asthma who are moderately to severely ill on arrival and who have little improvement or worsen after initial therapy with beta-agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting and poor aeration, and who require beta agonist therapy more often than every 4 hours. 
This patient continued to have significant symptoms after initial therapy and required albuterol treatments more often than every 2 hours. Therefore, hospitalization was necessary. 

The decision making at the time of admission for this patient was consistent with the patient's age, the presence of ongoing severe respiratory symptoms despite appropriate emergency treatments, and the need for ongoing frequent treatments (initially every 2 hours) along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: General debility and Ambulatory difficulty. 
Treatment: Continued Skilled Nursing Facility. 
The insurer denied the Continued Skilled Nursing Facility. 
The denial is overturned. 

The patient is a female with history of general debility, with her general debility and ambulatory difficulty being due to left hip metastasis status post left hip fracture from metastatic liver cancer/chongiocarinoma status post radiation therapy and admitted to acute hospital. 

The patient's relevant past medical history includes Essential Tremor, malignant neoplasm of liver with bone metastases, major depression, pain, respiratory tuberculosis, hypertension, etc. 

The patient was admitted Non-Weight-Bearing (NWB) Left Lower Extremity. She is DNR/DNI (do not resuscitate/do not intubate). 

The patient's ongoing medical issues include thrombocytopenia and hypovolaemia while awaiting chemotherapy. In addition she has lytic lesions posterior left iliac bone, left inferior ramus, and the patient does not want any surgical intervention. 

Prior to admission the patient was living alone in a condominium, independent with ADLs (activities of daily living) and driving while going to work. 

The patient was admitted to SNF (skilled nursing facility) requiring maximum assistance for ADLs (activities of daily living). She was ambulatory with wheelchair, she required maximum assistance for bed mobility, transfers, dressing, contact-guard with toileting, independent with bathing. 

Yes, the requested Continued Skilled Nursing Facility is medically necessary. 

The patient has liver cancer with metastases and associated general debility. She has ambulatory difficulty, being NWB (non-weight bearing) Left lower extremity due to metastases and pathological fracture Left hip. Her admission was to SNF (skilled nursing facility). She required maximum ADLs (activities of daily living). She also had thrombocytopenia and hyponatremia. 

The patient was still requiring ambulatory with wheelchair, she required maximum assistance for bed mobility, transfers, dressing, contact-guard with toileting, independent with bathing. 

Therefore, stay in SNF (skilled nursing facility) was medically necessary and thereafter to custody care while awaiting further treatment for her medical conditions. 

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

Diagnosis: Dementia.
Treatment: Home health care - PCA (personal care aid) Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week.
The insurer denied Home health care - PCA Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, hypertension, edema, diabetic nephropathy, peripheral vascular disease, osteoarthritis, urinary incontinence, coronary artery disease, and permanent pacemaker who had been assigned PCA (personal care aide) services based on an assessment performed telephonically assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With tasks of phone use, the patient was assessed at limited assistance while supervision with task of eating. Prior to the assessment, the patient had a fall with injury and hospitalization. 

Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week are medically necessary for this patient.

There is documentation of worsening functional status following the patient's recent fall. The patient's cardiologist, neurologist, and PCP (primary care provider) document medical necessity of increased PCA services. The patient has at least maximum assistance need with all tasks except for eating. The insurer assumed the patient had informal help outside of the currently assigned hours but it is documented in the advocate letter that the patient's son is only available 8-9 pm to 7 am as he is working and does require sleep in the overnight hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient has unpredictable and unscheduled care needs outside of the hours she has informal help and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Daytime Sleepiness, Sleep Paralysis, Cataplexy
Treatment Multiple sleep latency testing (MSLT) and baseline sleep study in a facility
The insurer denied multiple sleep latency testing (MSLT) and baseline sleep study in a facility.
The determination is overturned.

The patient suffers from daytime sleepiness. The patient had a home sleep study and was ruled out for sleep apnea. The patient reports symptoms of sleep paralysis and cataplexy. The treating provider is requesting the coverage of a polysomnogram (PSG) followed by a Multiple Sleep Latency Test (MSLT) to rule out sleep apnea and these are under review for medical necessity.

Yes, the requested health service/treatment of multiple sleep latency testing (MSLT) and baseline sleep study in a facility is medically necessary for this patient.
Narcolepsy is a serious, life-long, potentially disabling disorder. Symptoms are usually first noticed during the early teenage years. There is no known cure for narcolepsy and no completely adequate treatment is available. Narcolepsy is a chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. At various times throughout the day, people with narcolepsy experiences fleeting urges to sleep. If the urge becomes overwhelming, individuals will fall asleep for periods lasting from a few seconds to several minutes. In addition to excessive daytime sleepiness (EDS), three other major symptoms frequently characterize narcolepsy: cataplexy or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or upon awakening; and brief episodes of total paralysis at the beginning or end of sleep.
The MSLT is performed to evaluate the presence of pathological sleepiness and to confirm the diagnosis of Narcolepsy. These individuals are studied during 5 daytime naps taken 2 hours apart. The mean MSLT score is usually less than 8 minutes.
According to the American academy of sleep medicine (AASM) an in lab sleep study current procedural terminology (CPT) 95810 followed by MSLT CPT 95805 is indicated as part of the evaluation of patients with suspected narcolepsy to confirm the diagnosis.
According to the Milliman care guidelines, MSLT is indicated if narcolepsy suspected on basis of 1 or more of the following:
-	Excessive daytime sleepiness
-	Disturbed or fragmented sleep
-	Cataplexy (ie, sudden weakness or loss of muscle tone not accompanied by loss of consciousness)
-	Hallucinations with sleep onset (hypnagogic) or upon awakening (hypnopompic)
-	Sleep paralysis
The review of this patient's records revealed that the patient was referred to the sleep lab for evaluation of daytime sleepiness. The patient has specific symptoms of narcolepsy including sleep paralysis and cataplexy. The patient was ruled out for sleep apnea. Therefore, the in lab sleep study CPT 95810 and MSLT CPT 95805 were medically necessary for the evaluation of this patient for possible narcolepsy.