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

Diagnosis: Infertility
Treatment: Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and the biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); greater than 5 embryos
The insurer denied biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and the biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); greater than 5 embryos.
The determination is overturned.


The patient is seeking pregnancy with in vitro fertilization (IVF). At issue is the medical necessity of preimplantation genetic test for aneuploidies (PGT-A) testing on the embryos.

Yes, the PGT-A requested by the patient is medically necessary. Due to normal ovarian aging, greater than 90% (percent) of the embryos she creates with her own eggs will be chromosomally abnormal and most of those non-viable. Without PGT-A, she will likely create embryos but she will be unable to see which ones are likely to yield a successful pregnancy. She will then have embryo transfers that will likely not yield pregnancy and those that do yield pregnancy will likely miscarry due to chromosomal abnormalities. This time used for unfruitful embryo transfers is exceptionally critical as the patient might decide to try another IVF cycle to create more embryos. The difference in a few months can make a difference in the chance of successful pregnancy.

In the references cited, there is clear evidence that PGT-A is an established and efficacious adjunct to IVF, especially in the case of this patient as the vast majority of the embryos she creates with her own eggs are chromosomally abnormal. PGT-A allows select transfer of chromosomally normal embryos which have a much higher chance of creating a successful pregnancy.
Appeal type: Medical necessity
Decision: Upheld

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


This patient who presented to the hospital following a fall. His trauma evaluation identified an elevated heart rate of 116 beats/minute at presentation. The evaluation also included imaging with a computed tomography (CT) scan that identified a 10.3-centimeter (cm) hematoma in the subcutaneous tissues at the left hip with active bleeding. The patient was admitted to the trauma service and monitored with serial hemoglobin checks. The hemoglobin was 14.6. Overnight, the patient received pain medications. The hemoglobin value was 12.8, then 12.7. He was considered to be stable for discharge.
At issue is the medical necessity of an inpatient stay.

No. The submitted records do not support the medical necessity of inpatient admission for this patient.
This patient presented following a fall. He had pain in the left hip and chest, but was without an identified fracture based on the trauma work up. The patient did have a subcutaneous hematoma in the area of the left hip with active bleeding per CT imaging. He was stable at the time of presentation though he did have a rapid heart rate of 116 beats/minute. Serial hemoglobin assessments identified an initial drop from 14.6 to 12.8 in the hemoglobin value but the patient did not require surgical intervention and the subsequent hemoglobin value was stable.
In this case, the care and treatment provided could have safely been rendered with a lower level of care rather than an inpatient level of care. That would allow for provision of IV (intravenous) fluid, IV pain medication, and overnight monitoring. The records support that this patient had an uncomplicated period of observation and was stable for discharge from the hospital in less than 48-hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Spinal Surgery/Decompression Surgery, 01 Unit. 
The insurer denied Spinal Surgery/Decompression Surgery, 01 Unit. 
The denial was upheld. 

This patient is a male with a history of back and leg pain. He has tried medications without relief. The neurologic exam shows no motor or sensory deficits. The lumbar magnetic resonance imaging (MRI) shows a large, extruded disc at lumbar (L)5-sacral (S)1 with severe canal compression. The provider has recommended an L5-S1 discectomy.
At issue is the medical necessity of Spinal Surgery/Decompression Surgery, 01 Unit.

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

The requested health service/treatment of Spinal Surgery/Decompression Surgery, 01 Unit is medically necessary for this patient.
The procedure is medically necessary. The patient has a large L5-S1 herniated disc and has back and leg pain. He did improve some with intravenous (IV) steroids, but his symptoms have returned. The patient has a risk of developing cauda equina syndrome, which could potentially cause irreversible neurological damage. The peer-reviewed literature supports surgery. Studies have shown better outcomes for patients with lumbar discectomy over continued conservative measures. Weinstein et al found "in a combined as-treated analysis at 4 years, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operatively treated patients in all primary and secondary outcomes except work status." Others have shown faster improvement with surgery, but similar outcomes in 2 years. Peul et al cite "early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year." In this case, the patient has failed conservative measures and has a large, herniated disc that corresponds to the symptoms, which are clear indications for surgery. Therefore, the requested health service/treatment of Spinal Surgery/Decompression Surgery, 01 Unit is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; leg swelling
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with concerns of leg swelling and pain. Pertinent history included chronic venous insufficiency, venous stasis ulcers status/post (s/p) Unna boot treatment, obesity, eczema, and chronic obstructive pulmonary disease. The patient was placed in the hospital thereafter with an impression of right lower extremity cellulitis and chronic co-morbidities. 

The inpatient stay was not medically necessary. In this particular situation, none of aforementioned criteria for hospitalization, or continued hospitalization, were present. Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a failure of outpatient therapy, HbA1C (hemoglobin A1C) >(greater than)   10% (percent), limb-threatening infection, bacteremia, persistent altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, inability to maintain oral hydration, or severe pain requiring inpatient management. In addition, the patient did not require an associated surgical procedure (ie. abscess drainage, debridement) not amenable to outpatient, emergency department, or observation care or any other condition, treatment, or monitoring requiring inpatient admission.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Recurrent Miscarriages. 
Treatment: Outpatient Laboratory Tests. 

The insurer denied coverage for outpatient laboratory tests. 

The denial is upheld. 

According to the documentation submitted, this is a female with a history of recurrent miscarriages. She presented to the Reproductive Endocrinologist's office for the evaluation of recurrent miscarriages. The patient had C677T MTHFR (methylenetetrahydrofolate reductase) variant testing to investigate the cause of miscarriage. 

There is no evidence this variant is associated with an increased risk for miscarriages. The American Society for Reproductive Medicine (ASRM) advocates testing for Lupus anticoagulant on 2 or more occasions at least 12 weeks apart, anticardiolipin antibody of IgG (immunoglobulin G) or IgM (immunoglobin M) isotype in serum or plasma present in medium or hFigh titer on two or more occasions at least 12 weeks apart isotype in serum or plasma in titer greater than the 99th percentile present on two or more occasions at least 12 weeks apart when the clinical or family history is present. According to ASRM, screening for inherited thrombophilias (specifically factor V Leiden (blood cloth disorder) and the prothrombin gene mutations protein C (blood cloth prevention), protein S(blood cloth prevention), and the antithrombin deficiencies) may be clinically justified when a patient has a personal history of venous thromboembolism in the setting of a non-recurrent risk factor (such as surgery) or has a first degree relative with a known or suspected high-risk thrombophilia. 

In summary, there is no benefit to encourage outpatient laboratory testing for thrombophilia in such a patient as noted above. The peer-reviewed literature does not support an improvement in health outcome with this outpatient laboratory testing. Thrombophilia testing is not supported by the appropriate regulatory bodies for this diagnosis. This patient was not a good candidate for this outpatient laboratory testing. Furthermore, adverse risks could be increased if this patient is over treated based upon these tests if being anticoagulated unnecessarily. 

In conclusion, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of outpatient laboratory should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Recurrent Miscarriages. 
Treatment: Outpatient Laboratory Tests. 

The insurer denied coverage for outpatient laboratory tests. 

The denial is upheld. 

The patient is a female with a history of recurrent miscarriages. She presented to the Reproductive Endocrinologist's for the evaluation of recurrent miscarriages. The patient had C677T MTHFR (methylenetetrahydrofolate reductase) variant testing to investigate the cause of miscarriage. 

There is a large and contradictory body of literature on the association between maternal inherited thrombophilia and recurrent spontaneous abortion, fetal loss, and stillbirth. 

The American College of Obstetricians and Gynecologists states that tests for thrombophilias are not required as part of the evaluation of recurrent pregnancy loss but may be considered in cases of otherwise unexplained fetal death in the 2nd or 3rd trimesters. "The role of thrombophilia in recurrent pregnancy loss is a controversial subject of current research interests. Tests for factor V Leiden (blood cloth disorder), the prothrombin G20210A (abnormal blood cloths) mutations, or deficiencies of protein C (blood cloth prevention), protein S (blood cloth prevention, or antithrombin III should be considered in cases of otherwise unexplained fetal death in the second or third trimesters. However, the role of these heritable thrombophilias in recurrent early pregnancy loss is uncertain at present, and tests for these thrombophilias are not required as part of the evaluation. Whether antithrombotic treatment improves subsequent pregnancy outcomes in women with evidence of thrombophilia is uncertain." (1) 

Based on the lack of association with negative pregnancy outcomes, the American College of Obstetricians and Gynecologists does not recommend MTHFR (methylenetetrahydrofolate reductase) gene mutation analysis or homocysteine level. 

Based on the above the thrombophilia panel done on this patient was experimental/ investigational and unproven and therefore not medically necessary. The requested procedure is not likely to be more beneficial than any other existing standard health service. 

The carrier's denial of outpatient laboratory tests, thrombophilia test, should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Precocious Puberty. 
Treatment: Lupron Depot. 

The insurer denied Lupron Depot. 
The health plan's determination is upheld. 

The patient is a female who is seeking treatment with Gonadotropin-releasing hormone (GnRH) analogue (Lupron Depot) for precocious puberty. Her mother is 4' 10''(feet/inch) and her father is 5' 11'' tall. Her mother reached menarche at age 9 years.
This patient was seen in the pediatric endocrinology clinic for pubertal changes started few months ago. She had Tanner stage II-III breast development and Tanner II pubic hair. Clinical impression was early end of normal puberty. Her evaluation showed luteinizing hormone (LH) 1.2, follicle-stimulating hormone (FSH) 4.6 and Estradiol 51. Treatment with Lupron Depot was recommended. 

Lupron Depot is not medically necessary for this patient. 

GnRH analogs are standard of care for treatment of central precocious puberty. Common reasons for GnRHa treatment are potential for compromise in adult height, inability to adapt to menarche at young age, and psychosocial difficulties. 
Besides suppressing puberty, GnRHa can also decrease growth velocity to below prepubertal rate which can minimize any gain in stature. The greatest height gain (average gain 9-10 cm) with GnRHa treatment has been observed in girls with onset of puberty at less than 6 years. When puberty begins in girls before the age of 7 years and is progressive, the decision to treat is mandatory to preserve height potential. However, treatment at the age of 9 years cannot be justified. Advanced bone age with compromised adult height is the rationale for GnRHa treatment in this case. However, based on the guidelines for the treatment of precocious puberty, GnRHa therapy in children with short stature and normally timed puberty is minimally effective in increasing adult height and cannot be suggested for routine use. 
This patient's puberty is considered early but not precocious. Her exam showed breast development Tanner II-III which is also consistent with early not precocious puberty.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Caries. 
Treatment: Deep sedation/general anesthesia first 15 minutes (D9222) and each subsequent 15-minute increment (D9223). 

The insurer denied coverage for deep sedation/general anesthesia first 15 minutes (D9222) and each subsequent 15-minute increment (D9223). 

The denial is overturned. 

Based on the submitted clinical documentation including narrative letter from the patient's father in addition to insurer correspondence, it appears this child with severe dental decay and extensive dental needs and documented sensory processing and situational anxiety presented for dental treatment.  Due to poor compliance in the outpatient setting because of the patients underlying medical issues, it was recommended that all dental treatment be performed under deep sedation. 

Upon review of the documentation submitted and as enumerated above, this patient had significant dental needs that would be difficult to provide in the outpatient setting due to significant dental disease, age of the patient and poor compliance/anxiety due to the patient's underlying medical issues and sensory processing issues. Therefore, it was recommended that all treatment be performed in a controlled setting under deep sedation/general anesthesia. This provides the benefit of completing all dental needs at one time and anesthesia assures patient compliance. This is a standard of care treatment for this clinical situation when dealing with pediatric patients. This treatment is supported in the literature (see below). Further, the treatment plan as recommended fulfills and meets all of the Insurer's medical necessity criteria. As such the services recommended are considered medically necessary. 

Overturn denial of deep sedation/general anesthesia first 15 minutes (09222) and each subsequent 15-minute increment (09223).  The treatment as recommended meets the insurer's criteria for medical necessity and would be a standard of care in pediatric dental practice. 

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

Deep sedation/general anesthesia first 15 minutes (09222) and each subsequent 15 -
minute increment (09223) is considered medically necessary for this patient. 

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

The insurer's denial of coverage for deep sedation/general anesthesia first 15 minutes (D9222) and each subsequent 15-minute increment (D9223) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease. 
Treatment: Repatha 140MG/ML SC SOSY. 

The insurer denied the Repatha 140MG/ML SC SOSY. 
The denial is upheld. 

This male was referred for Repatha therapy. His PMH (past medical history) is pertinent for known CAD (coronary artery disease) by MI (myocardial infarction) treated with PCI (percutaneous coronary intervention), smoking, HTN (hypertension), HLP (hyperlipidemia), very poor diet and no exercise. LDL (low-density lipoprotein) was 99 on taking atorvastatin 80 mg and Zetia. The requested Repatha has been denied as not medically necessary by his Plan and the member is appealing the decision. 

No, the proposed treatment is not medically necessary. 

There is insufficient information submitted that only Repatha can treat this member's HLP (hyperlipidemia) with clinical ASCVD (atherosclerotic cardiovascular disease) and LDL(low-density lipoprotein) not at goal of < [less than] 70. Lipid lowering therapies (statins, Zetia and therapeutic lifestyle changes) are central strategies in the primary and secondary prevention of ASCVD (atherosclerotic cardiovascular disease). There is sufficient information submitted that the member is noncompliant, including still smoking, eating unhealthy and no exercise. The records should reflect that the member has made serious attempts at TLC (therapeutic lifestyle changes) and unable to reach his LDL (low-density lipoprotein) goal < [less than] 70, before the request can be considered medically necessary. 

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

Diagnosis: Dizziness. 
Treatment: Inpatient admission. 

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

The patient is a male who presented to the emergency room with intermittent episodes of lightheadedness, diplopia, nausea, and vomiting on the day of admission, he endorsed and unsteady gait and feeling like his balance was off. Computed tomography angiography (CTA) of the head and Computed tomography angiography (CTA) of the head and neck revealed left cervical vertebral artery stenosis of the proximal right internal carotid artery and occluded left intradural vertebral artery. Neurology was consulted and recommended vascular evaluation and carotid duplex. Inpatient care included frequent neurological checks and initiation of aspirin, Plavix and Lipitor, and Magnetic Resonance Imaging/Magnetic resonance angiogram (MRI/MRA) of the head. Vascular noted that the patients symptoms were most likely caused by vertebral occlusion. The following day, patient was feeling better and was subsequently discharged to be followed as an outpatient. 

Yes, the proposed treatment is medically necessary. 

Inpatient admission was medically necessary as the patient was having neurological symptoms and was at a very high risk for a catastrophic stroke. The patient required frequent neurological checks to ensure that he would not develop a stroke. It is standard of care for those who are having neurological deficits to be monitored frequently with neurological checks and telemetry which cannot be provided in the outpatient setting. 

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

The health plan did not act reasonably as one with a high risk of a stroke cannot be observed in the outpatient setting because of the risk of needing thrombolytics and the short window available to provide thrombolytics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis Vulgaris
Treatment: Dupixent 300mg (milligrams)/2ml (milliliters) SOSY (solution prefilled syringe)
The insurer denied the Dupixent 300MG/2ML SOSY.
The denial is upheld.

The patient is a male with psoriasis, erythrodermic.  He has been treated with topicals and Tremfya.  The provider is requesting Dupixent.

No, the proposed treatment is not medically necessary.

Dupixent is not an approved medication for psoriasis.  It should absolutely be avoided in psoriasis.  This is not consistent with standard of care and acceptable medical practices.  Dupixent worsens Th-1 (Type 1 T helper) driven conditions such as psoriasis.

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

Diagnosis: Low Back Pain.
Treatment: Intracept procedure (22899 and C9752).
The insurer denied the Intracept procedure (22899 and C9752).
The denial is upheld.

The patient is a female with a history of chronic low back pain. Her pain has not responded to medial branch blocks, surgery, physical therapy (PT), and pain medication. She has tried various medications. Physical exam shows decreased range of motion (ROM), and tenderness on palpation.

An Intracept procedure has been recommended. The procedure was denied coverage by the health plan as experimental/investigational. This was appealed.

No, the health plan should not cover the Intracept procedure.
The patient is a female with a history of chronic low back pain. Her pain has not responded to medial branch blocks, surgery, physical therapy (PT), and pain medication. She has tried various medications. Physical exam shows decreased range of motion (ROM), and tenderness on palpation.

An Intracept procedure has been recommended. The procedure was denied coverage by the health plan as experimental/investigational. This was appealed.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.

However, the patient has not failed sacroiliac (SI) joint interventions, which is a common cause of axial low back pain. Chronic opiates are not without risk, and can lead to addiction and overdose. Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence-proven alternatives have failed.  Given the above, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial.
Alternatives exist, and have been shown to be beneficial.