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

Diagnosis: Bilateral eyelid ptosis

Treatment: Codes 67400- Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy and 67904- Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

The insurer denied coverage for codes 67400- Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy and 67904- Repair of blepharoptosis; (tarso) levator resection or advancement, external approach.

The denial is overturned.

The patient is a female with a history of visual deficits, hypertension, and kidney cancer. The patient presented to an ophthalmologist for an evaluation. On examination, the patient's visual acuities were 20/20 in both eyes. She had prolapsed lacrimal glands. She had ptosis of both upper eye lids with loss of severe superior visual field.  The visual field normalized with lids taped up.  The ophthalmologist recommended repairing ptosis of both upper eyelids.

The patient underwent transblepharoplasty superior orbitotomy with repositioning of lacrimal gland and repair of blepharoptosis/brow ptosis in the right eye and left eye. On post-operative exam it was noted that the patient was doing well after her ptosis repair. 

The procedure was medically necessary to improve this patient's vision.  Frontal and lateral photos document redundant upper eyelid skin with clear extension of the upper lid over the lashes and affecting the visual axis.  There were also prolapsed lacrimal glands on exam.  The patient's visual field testing confirmed functional superior field defects in both eyes that improved with taping of the eyelids.  In addition, the patient reported that her eyelids affected her vision and her eyelids felt heavy.  The patient's clinical exam showed bilateral upper eyelid dermatochalasis, frontal and lateral external photographs documenting excess upper eyelid skin affecting the visual axis, and her visual field testing showed a superior field obstruction. All of these clinical findings support the determination that this procedure was medically necessary for this patient.

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

The carrier's denial of coverage for codes 67400 - Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy and 67904 - Repair of blepharoptosis; (tarso) levator resection or advancement, external approach should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Breast cancer.
Treatment:  Surgical procedure: excision, excessive skin and subcutaneous tissues (includes lipectomy); other area performed.

The insurer denied coverage for surgical procedure: excision, excessive skin and subcutaneous tissues (includes lipectomy); other area performed.  The denial is overturned. 

This is a female patient with a medical history of left breast cancer, who presented with excessive skin defect after her mastectomy.  The request is for excision, which includes lipectomy to allow for optimal healing without significant deformity and proper reconstruction. 

As per the Women's Health and Cancer Rights Act (WHCRA), insurers that offer benefits for mastectomy are mandated to provide coverage for breast reconstruction.  It states, "Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for certain services relating to the mastectomy in a manner determined in consultation with the attending physician and the patient.  Required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema."

In this case, the removal of the axillary tissue was necessary to allow the patient to wear prosthesis.  A large axillary dog ear post mastectomy can interfere with brassiere use and prosthesis fitting.  According to Clough, et al., "Following a mastectomy, both the cosmetic and functional results can be impaired by the presence of a lateral 'dog ear.'  This is a particular problem in women with a large body habitus giving an increased amount of adipose tissue lateral to the breast."  According to Lim and Tan, "Mastectomy is commonly performed for breast cancer.  However, a dog ear may arise at the lateral aspect of the mastectomy scar.  This dog ear is not only unsightly but can also be a source of discomfort."  The WHCRA mandates coverage for reconstructive procedures to allow use of prosthesis, and removal of the axillary dog ear was required to facilitate prosthesis and brassiere fitting.  Thus, surgical procedure: excision, excessive skin and subcutaneous tissues (includes lipectomy); other area performed was medically necessary for this patient.

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

Based on the above, the medical necessity for surgical procedure: excision, excessive skin and subcutaneous tissues (includes lipectomy); other area performed is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Nasopharynx carcinoma.
Treatment:  Proton Beam Radiation Therapy.

The insurer denied Proton Beam Radiation Therapy.  The denial is overturned.

The patient has a history of a nasopharynx carcinoma, staged tumor (T) 4 nodes (N) 2 metastasis (M) 0.  He was treated with chemotherapy and radiation therapy (protons) with excellent response.  He now has recurrent metastatic disease with leptomeningeal disease, as well as base of skull metastases.  Radiation therapy is recommended to treatment the craniospinal axis, and the proton beam approach is requested.  At issue is the medical necessity of proton beam radiation therapy.

The requested treatment of radiation therapy for metastases-proton beam therapy is considered medically necessary for this patient.  The recommended radiation therapy for this patient and his leptomeningeal metastases is medically appropriate, as chemotherapy is not the best option for this type of metastases.  The requested proton beam radiation to treat this patient's brain and spine is also medically appropriate and necessary, as this patient has had previous radiation to the base of skull and cervical spine region in 2018.  Proton radiation for reirradiation of this patient is the safest and best approach of treatment due to the physical characteristics of protons with its Bragg Peak that can have rapid drop off of high doses of radiation, which is needed in this patient in critical tissue areas, such as the spinal cord and brain stem.  There are excellent data published supporting the use of proton beam radiation for reirradiating head and neck areas, as well as for craniospinal irradiation.  The studies listed below have shown the significant decrease in volumes of spinal cord receiving high doses of radiation when previously irradiated by using the physical characteristics of proton beam radiation (Bragg Peak).  The use of proton beam radiation for this patient is beneficial for the same reasoning, as the reports listed which have shown a decrease in the risk of side effects, including neurologic compromises of weakness, paralysis, and sensory changes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Total Knee Arthroplasty
Treatment: Skilled Nursing Facility Stay
The insurer denied the Skilled Nursing Facility Stay
The determination is overturned.

The patient has a recent surgical history significant for left total knee arthroplasty revision and open reduction internal fixation (ORIF) of patella. The patient was subsequently admitted to a skilled nursing facility for post-acute rehabilitation. At issue is the medical necessity of skilled nursing facility stay.
The requested service of continued skilled nursing facility stay was medically necessary for this patient.
This patient underwent a left total knee arthroplasty revision and ORIF of the patella. The patient progressed well with therapy. He required moderate assist (MODA) for hygiene/grooming and upper body (UB) dressing. He required maximum assist (MAXA) for lower body dressing, toileting and bathing. Hygiene and grooming improved to contact guard assist (CGA) and remained CGA. UB dressing improved to CGA on and further improved. Lower body dressing, toileting and bathing remained MAXA but all did progress to MODA Bed mobility, transfers were MODA (25 feet with a wheeled walker (WW)) and all improved to minimal assist (MINA)(with distance increasing to 40') and then CGA followed by all improving to SBA (with distance increasing to 100').
Stair training had not occurred as this was not a goal. Initial therapy evaluation reports that the patient lived in a home with no stairs. But per documentation "When the social worker spoke to the family to arrange the discharge, they indicated the member lives on a second floor walk-up and would require stair training." Is understandable how this communication error occurred as the patient has bilateral deafness. It was appropriate and medically necessary to continue the patient's post-acute rehabilitation stay to focus on stair training. This occurred and therapy noted that the patient was ambulating 8 steps with stand by assist (SBA) and the patient was appropriately discharged. The patient lives alone and required the stair training to be able to be safely discharged.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Floor Prolapse.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld

This is a patient with a diagnosis of pelvic floor prolapse who was treated with a robot-assisted laparoscopic sacrocolpopexy and excision of old mesh. The surgery was uncomplicated. She had a prior hysterectomy and sacrocolpopexy. She received intravenous fluids (IVF) and pain medications. She was discharged home after an uneventful stay. She was tolerating a clear liquid diet. At issue is the medical necessity of an inpatient stay.
An acute inpatient level of care was not medically necessary.
Care could have been provided at a lower level of care. Following the procedure, robot-assisted laparoscopic sacrocolpopexy and excision of old mesh, there were no unstable vital signs reported. There were no postoperative complications reported. The was clinically stable. The post-operative care with clinical monitoring, pain medications and IVF administration did not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic migraines

Treatment: Ajovy

The insurer denied coverage for Ajovy.

The denial is upheld.

This is a female patient with frequent chronic migraines that have been impairing her quality of life considerably. Several prophylactic agents (beta blocker, tizanidine, and zonisamide) have been ineffective. The patient is afraid of needles and does not want to try Botox. The patient's neurologist prescribed Ajovy. This was denied by the insurer because she had not tried 3 preferred agents.  

The patient's provider states that it would be unethical to request the patient to use migraine prophylactic drugs which, unlike Ajovy, are not Food and Drug Administration (FDA)-approved.  However, as per literature review, valproate and topiramate are both FDA-approved for migraine prophylaxis. As per UpToDate, "A 2012 guideline from the American Academy of Neurology (AAN) concluded that topiramate and sodium valproate are established as effective for migraine prevention...  These two preferred agents are also commonly used for bipolar disorder, and this patient has bipolar disorder. 

Based on the review of the medical record, there is no clinical contraindication that this patient cannot trial on the preferred medications, such as valproate and topiramate. UpToDate article on Preventive Treatment of Migraine in Adults cites large randomized trials to support the efficacy of these anticonvulsant medications (valproate and topiramate) in reducing the frequency of migraine attacks. As per UpToDate, "data from one trial suggest that topiramate has residual benefit for migraine that persists for up to six months after the drugs is discontinued." Thus, the request for Ajovy is considered not medically necessary for this patient at this time.

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

The carrier's denial of coverage for Ajovy injection treatment for chronic migraines should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Misaligned Teeth.
Treatment:  Braces.

The insurer denied the braces.  The denial is upheld. 

The patient is a female.  The request is for orthodontic benefits.

No, the braces are not medically necessary.

There is no maxillary or mandibular crowding of the patients' teeth, according to the photos presented.  Therefore, the handicapping index scale is 12, not the 26 the provider indicated.  As such, no benefits are mandated.  Treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic graft versus host disease, Hodgkin's lymphoma

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is upheld.

This is a female patient with a past medical history significant for Hodgkin's lymphoma, status post chemotherapy with incomplete response who presented to the Emergency Department (ED) with complaints of a painful, erythematous rash on her left knee. In the ED, the patient's vital signs on presentation were: Temperature 98.8, Blood Pressure 147/89, Heart Rate 100, Respiratory Rate 20, Oxygen Saturation 98% on room air. The patient's first set of laboratory results showed: white blood cell (WBC) count 7.2 and blood urea nitrogen /creatinine of 26/0.69. The patient was started empirically on intravenous (IV) antibiotics (i.e., vancomycin and cefepime) for a possible cellulitis, and chronic graft versus host of skin fascia. Multiple services were consulted over this case, including Infectious Diseases, Dermatology, and Pulmonary. The patient complained of dyspnea on exertion for which her computed tomography (CT) scan showed diffuse bilateral ground glass opacities and small bilateral pleural effusions. The patient's respiratory viral panel was positive for Influenza A. The patient's treatment included prednisone and infection prophylaxis with acyclovir, voriconazole, Bactrim and penicillin V potassium. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged on day 12 of admission to continue outpatient management. 

According to documentation, the patient presented to the hospital with left knee swelling and erythema. Otherwise, the patient was afebrile, hemodynamically stable with stable laboratory results including a normal WBC count. The patient had no evidence of a disseminated infection and no surgical intervention was required. Medical records indicate that the patient had chronic graft versus host disease without evidence of acute infection. Based on the above findings and literature review, the patient met criteria for an observation level of care. Inpatient admission was not medically necessary.  

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

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Right foot pain and swelling.
Treatment:  Inpatient admission.

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

The patient is a male whose inpatient admission is under review.  The patient has a history of HTN (hypertension), a-fib (atrial fibrillation), and left foot osteomyelitis.  He presented to the hospital with right foot pain and swelling after having failed outpatient treatment with ten days of Augmentin.  The patient's presentation was notable for worsening erythema, swelling in right first toe, and pain in toe.

In the ER (emergency room), the patient's vitals were as follows:  T (temperature) - 97.6, P (pulse) - 110, RR (respiration rate) - 18, and BP (blood pressure) - 164/83.  On general examination, the patient was noted to be NAD (no acute distress).  Examination of the patient's chest was normal.  Examination of the patient's CVS (cardiovascular system) revealed tachycardia.  Examination of the patient's abdomen was normal.  Examination of the patient's extremities reveal swelling and erythema of the right foot, open wound in right first toe. 

The patient's labs were as follows:  WBC (white blood count) - 13.5 (high), Hg (hemoglobin) - 15.1, Hct (hematocrit) - 42.1, Plt (platelets) - 135, Na (sodium) - 139, K (potassium) - 3.8, Cl (chloride) - 106, CO2 (carbon dioxide) - 22.8, BUN (blood urea nitrogen) - 16, and Cr (creatinine) - 1.2.

The patient's foot x-ray revealed amputation of first digit at distal proximal phalanx, as well as soft tissue swelling and irregularity.

In the ER, the patient was thought to have right foot cellulitis and ulcer, and he was admitted for IV (intravenous) antibiotics and management.  An MRI (magnetic resonance imaging) ruled out osteomyelitis, but did show an abscess, which was incised and drained.  Afterwards, the patient was discharged on PO (oral) antibiotics.

Yes, the Inpatient admission was medically necessary.

Inpatient admission was indicated for the following reasons:  1) Systemic signs of infection (tachycardia and elevated WBC [white blood cell] count) (1), and 2) Failure of outpatient therapy (1), as noted in the clinical summary, above.

Thus, this admission was warranted, supported by Infectious Diseases Society of America (IDSA) guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lyme Disease
Treatment: Pharmacy/Prescription Drugs (Alinia)
The health plan denied the Prescription Drug
The health plan's determination of medical necessity is upheld, in whole


The patient is a woman with reported Lyme disease. Laboratory testing demonstrated Lyme IgM (Immunoglobulin M) positivity but Lyme IgG (Immunoglobulin G) was negative (per Centers for Disease Control criteria). Babesia FISH (fluorescence in-situ hybridization) testing, Babesia duncani IgM, and Bartonella IgM testing was also positive. No clinic records or physician documentation were provided. This patient's physician is requesting Alinia (Nitozoxanide) 500 mg tablets.

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

No. The requested treatment (Alinia 500 mg tablets) is not medically necessary for this patient.

The materials provided include broad laboratory testing for tick borne illness. Positive results included Lyme IgM, Bartonella IgM, and Babesia duncani IgM. In the absence of clinical context, these results do not confirm the presence of a tick-borne illness. The requested Alinia (nitazoxanide) broad-spectrum antiparasitic and antiviral drug that is used for the treatment of various helminthic, protozoal, and viral infections. There is no evidence this drug is effective in treating Lyme disease, babesiosis or bartonellosis. There is no evidence this patient has a parasitic or viral illness. Based on the materials provided, the health plan appropriately determined the requested Alinia (Nitozoxanide) is not medically necessary for this patient.

As stated above, Nitozoxanide has demonstrated activity in certain parasitic or protozoal infections (e.g. Cryptosporidium, Giardia). The drug is also being evaluated for efficacy against certain viruses, including influenza, hepatitis B virus, and hepatitis C virus. There is no evidence this drug has activity against agents which cause tick or insect borne illness, including Borrelia, Babesia, and Bartonella. Based on the current medical literature, the requested Alinia (nitozoxanide) 500 mg tablets must be considered not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CHF, Atrial Fibrillation, Peripheral Vascular Disease and Gait Ataxia
Treatment: Personal Care Services - 24 hours (live-in), 7 days per week, total of 91 hours per week
The insurer denied the Personal Care Services - 24 hours (live-in), 7 days per week, total of 91 hours per week.
The denial is overturned. 

The patient is a male with a history of Congestive Heart Failure (CHF), Atrial Fibrillation, Peripheral Vascular Disease and Gait Ataxia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 24 hours (live-in), 7 days per week, total of 91 hours per week Personal Assistance Services to offer increased ADL support.

Yes, the Personal Care Services - 24 hours (live-in), 7 days per week, total of 91 hours per week is deemed medically necessary. 

This is a male with a history of Congestive Heart Failure, Atrial Fibrillation, Peripheral Vascular Disease and Gait Ataxia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to worsening functional decline, the patient requires 24/7 care and assistance with transferring, turning, positioning and incontinence care to prevent pressure ulcers. The health plan's currently approved care plan of Personal Care Services, 10 hours per day, 7 days per week, for a total of 70 hours per week is not sufficient to meet the patient's needs. For these reasons, the proposed treatment 24 hours (live-in), 7 days per week, total of 91 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney infection
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of appendectomy.  She presented to the hospital with subjective fevers and right lower quadrant and back pain.  The patient had been recently initiated on treatment with ofloxacin as an outpatient.  

On presentation, the patient's temperature was 103.1 with a blood pressure 91/48.  On admission the blood pressure was 110/64 with a pulse 92.  Labs were notable for a sodium 134, bicarbonate 22, potassium 3.9, creatinine 0.7, hemoglobin 11.4, and white blood cell count 7.4.  The examination demonstrated right cerebrovascular tenderness to palpation.  Urinalysis was positive for white blood cells, red blood cells, and leukocyte esterase.  Computed tomography of the abdomen/pelvis demonstrated right pyelonephritis and ureteritis as well as a likely simple cyst.  Intravenous fluids and intravenous antibiotics were provided.  A renal ultrasound demonstrated no mass.  Blood and urine cultures were negative.

No, the Inpatient admission was not medically necessary.

The patient presented with a fever and was felt to have pyelonephritis.  However, the patient did not have vomiting, altered mentation, hemodynamic instability, immunocompromised state, or acute kidney injury.  The patient was not pregnant.  The patient did not have persistent fever, vomiting, persistent pain, or persistent dehydration beyond observation care.  There was no urinary anatomic abnormality such as obstruction and there was no indwelling ureteral stent.  The patient did not have a solitary kidney or transplant kidney.  There was no evidence of hydronephrosis, pyelonephritis, granulomatous or emphysematous pyelonephritis, or renal or perinephric abscess.  Blood and urine cultures were negative.  Inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.