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

Diagnosis: Cardiac/Circulatory Problems/Varicose Veins.
Treatment: Surgical Services/Left Leg Vein Sclerotherapy.
The health plan denied the requested surgical procedure due to the lack of medical necessity. 
The health plan's determination is overturned.

The patient is a female who presents with left leg symptomatic varicose veins. Her main symptoms include burning, aching and itching. She works as a teacher and her symptoms interfere with her activities of daily living. She has attempted and failed conservative therapy with graded compression stockings without symptomatic relief. She has undergone prior ablation of her left great saphenous vein. Her provider is recommending left leg vein sclerotherapy for treatment of her condition.
At issue is the medical necessity of the requested procedure.

I recommend overturn, in whole of the health plan's determination of medical necessity.

Yes. Left leg vein sclerotherapy x 3 (36471 x 3) is medically necessary based on the peer reviewed literature.
The patient presents with residual symptomatic left leg tributary varicose veins despite prior ablation of her left great saphenous vein. Her duplex ultrasound demonstrates that her left great saphenous vein has been successfully occluded, however the patient continues to have lifestyle limiting symptoms. She has attempted and failed conservative therapy with graded compression stockings. Left leg vein sclerotherapy is medically necessary for this patient based on the peer reviewed literature for treatment of her residual and symptomatic left leg tributary veins. Leg vein sclerotherapy is strongly supported by the peer reviewed literature for treatment of superficial, residual varicose veins following saphenous vein ablation. It is also supported by the most recent consensus guidelines by the Society for Vascular Surgery and the American Venous Forum. Leg vein sclerotherapy is considered a standard of care treatment for symptomatic, residual varicose veins. Three sessions are consistent with the standard supported in the peer reviewed literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria
Treatment: Facial feminization surgery
The insurer denied coverage for facial feminization surgery (rhinoplasty, face lift, and genioplasty)
The denial is overturned 

The patient is a transgender female with a history of gender dysphoria and depression. The physician is requesting facial feminization surgery, rhinoplasty, face lift, and genioplasty to treat this patient's gender dysphoria.

According to the World Professional Association for Transgender Health (WPATH) guidelines, surgeries for assisting in body feminization include reduction thyroid chondroplasty, voice modification surgery, suction-assisted lipoplasty of the waist, rhinoplasty, facial bone reduction, face-lift, and blepharoplasty.  Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants.

Although most of these procedures are generally labeled purely aesthetic, these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures. In this case, this patient has anxiety that this patient's mental health providers attribute directly to facial gender incongruity. The patient has significant dysphoria that the patient's physician believes is secondary to the incongruence of the patient's facial appearance with this patient's assigned sex.  A study by Ainsworth and Spiegel (2010) found improved mental health functioning for transgender women following facial feminization surgery.  In this case, this patient's condition represents a unique clinical situation for which facial feminization is considered medically indicated.  A systematic literature review on facial feminization by Morrison et al. (2016) concluded that "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients."  

The requested procedures are necessary to treat this patient's unique clinical situation of disabling gender dysphoria and posttraumatic stress disorder (PTSD) related to the incongruence of this patient's facial appearance.

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

The insurer's denial of coverage for Facial Feminization Surgery, Rhinoplasty, Face Lift, and Genioplasty (Procedure Codes 15824, 21120, 21139, 30410) is substantiated.  The insurer's denial should be overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Open Angle Glaucoma
Treatment: Lumigan (bimatoprost)
The health plan denied Lumigan (bimatoprost).
The determination is overturned.

The patient has open angle glaucoma, including optic nerve ganglion cell layer thinning and visual field loss who has had his pressure well controlled on a regimen of bimatoprost, dorzolamide/timolol, and brimonidine. He has previously been treated with latanoprost and travoprost Z without appropriate control of his intraocular pressure. At issue is whether the formulary drug(s) would be as effective as the non-formulary drug or would have adverse effects.

Per the note from the provider, the patient has previously been treated with latanoprost and travaprost without adequate control of his intraocular pressure (IOP). Putting him back on the ineffective medications for the purpose of demonstrating that his intraocular pressure might rise, risks further loss of vision and potential blindness in the patient with open angle glaucoma. Several studies have demonstrated that bimatoprost has superior IOP lowering effects to latanoprost. A recent meta analysis of the efficacy of prostaglandin analogues found that 0.03% bimatoprost appears more effective following long time use (3 and 6 month post-treatment) for IOP control compared to 0.005% latanoprost, and is more effective compared to 0.004% travoprost after being used for a certain period of time (3 months post-treatment). Further, it is standard of care for most ophthalmologists to replace latanoprost/travoprost with bimatoprost if a patient is on maximal medical therapy for glaucoma but still does not have adequate control over the IOP.
This patient has been on formulary alternatives in the past without control of his IOP. He is currently receiving a mixed regimen of two formulary medications, dorzolamide/timolol (cosopt) and brimonidine (alphagan) in addition to the bimatoprost. This regimen is fairly common in patients with advanced glaucoma who require better IOP control. Bimatoprost is currently controlling his pressure and should be continued to ensure he maintains the best possible vision. This is a Food and Drug Administration (FDA) approved usage of the medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes.
Treatment: Inpatient Hospital/Acute Rehabilitation.
The health plan denied the request for an acute rehabilitation admission. 
The health plan's determination is overturned.
 
This patient is a male. The request is for admission to a chronic illness management program. The patient has poorly controlled type I diabetes. He has a history of chronic medical noncompliance, hyperglycemia, possible depression and anxiety, atopic dermatitis, asthma, and hereditary persistence of fetal hemoglobin. He uses an insulin pump and continuous glucose monitor. The patient was recently admitted with severe diabetic ketoacidosis (DKA) despite engaging in weekly outpatient therapy to help with acceptance of his diabetes. He has had high blood sugars to the 300 - 400 range. He sleeps during the day and is up at night eating without administering insulin. The most recent hemoglobin A1c equivalent is 13 - 14%. He has been seen by his endocrinologist on a quarterly basis. He has been seen by the certified diabetes educator and he is seen weekly by therapist. The letter of medical necessity reports that there are no alternative outpatient chronic illness comprehensive management programs in the area.
At issue is the medical necessity of the requested rehabilitation facility admission.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The patient has type I diabetes with poor control and DKA admissions. The patient's treatment program has been intensified and despite frequent visits with the endocrine team, and referral to psychology, the patient has failed all outpatient treatment. The inpatient rehab program is reported to offer a higher level of daily interdisciplinary care including psychology, physical therapy, occupational therapy, recreational therapy, child life, medication and disease specific education, and nutritional counseling.
The program to which the patient has been referred improves family decision-making regarding diabetes, lifestyle choices and improvements in hemoglobin A1c. There are studies showing that such programs improve patient compliance, and diabetes control, as well as increase healthcare savings [1-6].
The intensive inpatient treatment program is expected to be health beneficial for the patient and is therefore medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Respiratory System
Treatment: Pharmacy/Prescription Drugs
The insurer denied: Dulera
The denial is upheld

The patient is a female with asthma. She has been treated with Dulera, which she has tolerated well. The patient was previously treated with Symbicort and Proventil but had palpitations. The subject under review is whether the formulary drug would be not as effective as the requested non-formulary Dulera or would have adverse effects.

The health plan's determination is upheld.

The history of palpitations following treatment with Symbicort and Proventil would have been attributable to Proventil and not to Symbicort. Thus, there is no documentation of a failure of or intolerance to Symbicort, nor is there evidence of a failure of or intolerance to Advair or Breo Ellipta. None of these agents is contraindicated in this case. In summary, the formulary drugs (Advair, Breo Ellipta, Symbicort) will be as effective as the non-formulary drug (Dulera), would not have adverse effects, and have not been ineffective for treatment of the patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation, stroke, COPD, dizziness,
memory loss, aortic aneurysm and chronic insomnia
Treatment: Increase Personal Care Services to Live-in Per Diem- 24 Hours Per Day, 7 Days Per Week
The insurer denied the Increase Personal Care Services to Live-in Per Diem- 24 Hours Per Day, 7 Days Per Week.
The denial is overturned. 

The patient is a female with a history of atrial fibrillation, stroke, COPD (chronic obstructive pulmonary disease), dizziness, memory loss, aortic aneurysm and chronic insomnia. 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 Live-in Per Diem- 24 Hours Per Day, 7 Days Per Week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of Live-in Per Diem- 24 Hours Per Day, 7 Days Per Week Personal Assistance Services is deemed medically necessary.

This is a female with a history of atrial fibrillation, stroke, COPD (chronic obstructive pulmonary disease), dizziness, memory loss, aortic aneurysm and chronic insomnia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Recent correspondence from the patient's medical provider indicates that due to multiple recent traumatic injuries resulting in a hip fracture and multiple brain bleeds, the patient has demonstrated significant progressively worsening functional decline. Therefore, the currently approved plan of 42 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of Live-in Per Diem- 24 Hours Per Day, 7 Days Per Week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Treatment: Cellulitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN) and epilepsy who was admitted with complaints of (c/o) erythema, pain, and swelling of the right elbow. Vital signs were unremarkable. The physical exam noted right elbow tenderness and mild edema. Lab work was notable for a C-reactive protein (CRP) of 51.4. An elbow radiograph showed no acute fracture or dislocation. The patient was diagnosed with right elbow cellulitis and treated with limb elevation, anti-inflammatories, and intravenous (IV) antibiotics. Of note, the patient suffered a breakthrough seizure due to the current medical illness. Neurology was consulted and recommended continuing home anti-convulsant regimen. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the Emergency department (ED) with c/o right elbow pain and swelling. She was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with intravenous (IV) antibiotics, specialty consultation, and limb elevation, and this could have been safely provided at a lower level of care. The patient did have a seizure during the hospital stay, but there was no change in therapy required as the cause was immediately apparent (active illness) and home medication regimen was continued and there were no repeat episodes or status epilepticus. Overall, this patient could have been safely treated at a lower level of care.

Regarding the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition: Cellulitis and MCG Health Inpatient & Surgical Care 24th Edition: Seizure, the patient did not have hemodynamic instability, severe altered mental status (AMS), failure of outpatient treatment, limb-threatening infection, rapid progression, severe acuity of infection, high-risk co-morbid condition, bacteremia, suspected necrotizing fasciitis, severe oral cellulitis, need for surgical procedure, cutaneous gangrene, orbital infection, compartment syndrome, status epilepticus, brain disorder, seizure etiology requiring inpatient care, cardiac arrhythmia of immediate concern, new focal neurological deficits, persistent metabolic disorder, recurrent seizures, cerebral bleeding, or increased intracranial pressure (ICP).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Epidural Steroid Injection for Pain Management.

The health plan denied the requested Epidural Steroid Injection for Pain Management.  The health plan's determination is upheld.

The patient is a female with complaints of lower back pain. The lower back pain is burning, constant, radiating into the left leg. The patient has had 3 past epidurals. With the epidurals, the patient is able to stand for much longer, has better mobility, and her quality of life has improved 90%. Physical exam demonstrated lumbar paravertebral tenderness, status post positive, strength is 5 out of 5, neurologically intact. A magnetic resonance imaging (MRI) of the lumbar spine demonstrated multilevel lumbar degenerative disc and facet disease.

At issue is the medical necessity of the requested service/treatment.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service/treatment of Outpatient Surgery: Epidural Steroid Injection is not medically necessary for this patient. The patient underwent three epidural injections in the past year. Any additional epidural injections at this point are excessive. Epidural injections are not a curative treatment, as evidenced by the 3 prior injections failing to provide substantial, sustained improvement in pain and function. As such, this request is not medically necessary for this patient.

The health plan appropriately denied the injection, as the patient had more than 4 epidural injections of the past 2 years, which is not standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient admission.

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

The patient is a female with seizure disorder who presented to the emergency ward after two witnessed seizures.  She had an additional seizure in the emergency ward. She had a non-focal neurological examination and her carbamazepine level was low.

No, the acute inpatient admission was not medically necessary.

The patient had a known seizure disorder and had documented sub therapeutic levels prior to presentation and at presentation. Therefore, the cause of her seizure was known. All necessary diagnostic studies were completed in the emergency ward. She had returned to baseline neurological status within 12 hours of presentation. Therefore, monitoring and treatment could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea, emesis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She has history of hypertension, COPD (chronic obstructive pulmonary disease), hyperlipidemia, Alcohol abuse, CAD (coronary artery disease), status post CABG (coronary artery bypass graft), stent placement. He had an EGD (esophagogastroduodenoscopy), which revealed erosive esophagitis, nonerosive gastritis, healing mallory weiss tear, and large hiatal hernia. She was seen as an outpatient and was advised surgery for hiatal hernia. She was referred to surgery, but she never followed up with Surgery. She was also advised to undergo esophageal motility study and pH (potential of hydrogen) study, but she did not have them done.

The patient was admitted to the hospital with abdominal pain, nausea and several episodes of nonbilious and nonbloody emesis. On admission, she was hemodynamically stable and afebrile. Her Hb/HCT (hemoglobin/hematocrit) were normal, and she had mild leukocytosis. Her chest x-ray, abdominal x-rays, and EKG (electrocardiogram) were normal.

The patient was started on IV (intravenous) fluids, PPI (proton pump inhibitor) BID (twice daily) and antiemetics (Zofran) for nausea and vomiting. She underwent CT (computed tomography) scan of the chest and abdomen. The CT (computed tomography) Chest revealed large hiatal hernia and esophagitis. The CT (computed tomography) abdomen was normal. She was made NPO (nothing by mouth) on admission. On IV (intravenous) fluids, her lactate levels, which were mildly elevated, normalized.

The patient was also started on IV (intravenous) steroids for the exacerbation of COPD (chronic obstructive pulmonary disease), and given duonebs. She improved over the subsequent 48 hours in terms of her respiratory symptoms, and switched over to prednisone PO (by mouth). Her nausea and vomiting resolved, and she was able to tolerate PO (by mouth). She was discharged on PPI (proton pump inhibitor) and Prednisone and advised to follow up with GI (gastroenterology) and PCP (primary care provider) as an outpatient.

No, the Inpatient admission was not medically necessary, for the management of this patient's condition.

The patient presented with abdominal pain, nausea and non-bilious and non-bloody vomiting. She had a prior history of erosive esophagitis, hiatal hernia and mallory-weiss tear. She was prescribed PPI (proton pump inhibitor) for erosive esophagitis and gastritis, but she was non-compliant with her medications due to insurance issue. On this admission, she was hemodynamically stable and afebrile, and her Hb/HCT (hemoglobin/hematocrit) were normal. She did not evidence any GI (gastrointestinal) bleed, and she did not require any blood transfusion. She was also treated for exacerbation of COPD (chronic obstructive pulmonary disease) with IV (intravenous) steroids. Her symptoms improved, and she was able to tolerate PO (oral) diet. Given this clinical scenario, she could have been safely managed under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse: Inpatient. 
The insurer denied inpatient substance abuse treatment for medical necessity. 
The denial was upheld.

The patient is a male referred for detoxification of alcohol use disorder. The patient was using alcohol with use of one liter of liquor and use of cocaine. He reported at least seven prior substance use treatments with detoxification episodes with relapse. 
The patient provided no history of severe alcohol withdrawal symptoms. His vital signs were normal, and his Clinical Institute Withdrawal Assessment (CIWA) scale score was 5 with mild symptoms. His chronic conditions included chronic obstructive pulmonary disease (COPD) with asthma/bronchitis, gastroesophageal reflux disease (GERD), Lumbago, and hypertension. He was medically screened and cleared for admission to detoxification treatment. 
There was psychiatric comorbidity diagnosed in this case best characterized as unspecified schizophrenia. He had a history of inpatient mental health stays with non-adherence to his medications. 
The patient was admitted for inpatient detoxification following the assessment for safety issues and medical clearance. He received vitamin replacement therapy, and other supportive measures including as needed (PRN).He was discharged with completion of the detoxification treatment with referral for appropriate aftercare and rehabilitation.
At issue is the medical necessity of Inpatient Substance Abuse Treatment: Medically Supervised Inpatient Detoxification.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Inpatient Substance Abuse Treatment: Medically Supervised Inpatient Detoxification was not medically necessary for this patient.
The patient in this case presented with continuous daily use of alcohol and cocaine. He did not have a history of complications from withdrawal or present with severe symptoms of withdrawal or a co-occurring psychiatric disorder or show abnormal findings on examination. He did not pose a safety risk that would have warranted the admission and continued inpatient level services.
The patient displayed no disturbance of mental status. The patient had been evaluated and cleared with regard to safety concerns in the emergency department and did not show evidence for suicidal or aggressive behavior or risk, severe cognitive impairment or psychosis, perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.
Thus, the requested health service/treatment of Inpatient Substance Abuse Treatment: Medically Supervised Inpatient Detoxification, was not medically necessary.