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

Diagnosis: Cervical radiculopathy with neck and arm pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a female with cervical radiculopathy and neck and arm pain. The patient failed physical therapy (PT), steroids and pain medications. Exam revealed no focal deficit. Computed tomography (CT) shows C5-7 degenerative disc disease. The patient was admitted to the hospital, underwent C4-6 anterior cervical discectomy and fusion (ACDF) the next day and was discharged one day later.

Yes, the inpatient hospital admission was medically necessary.
The patient presented to the emergency with worsening pain.  The imaging showed that the patient had stenosis and pain that was correlative.  The acute inpatient stay was medically necessary for pain management and to obtain imaging and neurosurgery consultation. The acute inpatient hospitalization was medically necessary due to the patient's surgery. For two level anterior cervical discectomy and fusions (ACDFs), acute inpatient hospitalization for one day of length of stay is considered medically necessary and therefore the date was also medically necessary.

The dates for acute inpatient hospitalization are all medically necessary and should be approved.
These were all medically necessary as mentioned above, and therefore should be covered by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented with nausea, vomiting and specks of black in yellow emesis. She was hypertensive and mildly tachycardic. There was a history of alcohol use, but her alcohol level was non-detectable.

The patient's Hgb (hemoglobin) was 11. CT (computed tomography) revealed thickening in the stomach and splenic flexure. She was seen by GI (gastroenterology), who noted 8 episodes of yellow vomitus with specks. She was hydrated, treated with PPIs (proton pump inhibitors) and anti-emetics. No GI (gastroenterology) workup was planned. She tolerated a diet. There was no ongoing vomiting, GI (gastroenterology) bleeding, diarrhea. Her follow-up Hgb (hemoglobin) was 9.9 and was felt to be related to hydration as there was no active bleeding. She was discharged.

No, the Inpatient admission was not medically necessary.
The patient had no significant anemia, no ongoing vomiting, and no evidence of significant bleeding. The patient was not hypotensive or tachycardic after initial hydration, and had no need for urgent endoscopy, and tolerated a diet. Therefore, the patient could have been treated at a lower level of care. Therefore, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As above, as the patient had no significant anemia, no ongoing vomiting, and no evidence of significant bleeding. The patient was not hypotensive or tachycardic after initial hydration. The patient had no need for urgent endoscopy, and tolerated a diet. Therefore, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Invasive squamous cell carcinoma of his left base of tongue.
Treatment: Proton Beam Radiation Therapy.
The insurer denied the Proton Beam Radiation Therapy.
The determination is overturned.


This is a patient with a history of prostate cancer and newly diagnosed clinical staging [c] tumor [T]1 nodes [N]1 metastasis [M] 0 invasive squamous cell carcinoma of his left base of tongue. He has been recommended to proceed with a course of definitive chemoradiotherapy with curative intent. At issue is the medical necessity of proton beam radiation therapy.

Yes, proton beam radiation is medically necessary and required in this patient's setting. The treating provider supplied a proton/photon plan comparison which revealed that the photon-based intensity modulated radiation therapy (IMRT) plan could not provide adequate safety/precision. Photon-based IMRT led to an excessive and potentially dangerous level of high dose exposure to the patient's oral cavity, parotid glands, and spinal cord. If delivered, the photon-based treatment plan would lead to an unnecessary and unacceptable risk for swallowing dysfunction and spinal cord injury. The proton radiation plan was able to significantly reduce the high dose exposure to within known safe tolerance limits, thereby minimizing the risk for serious toxicity. Proton radiation is supported by the American Society for Radiation Oncology (ASTRO) Model Policy and is widely utilized in such situations where IMRT is unable to meet nationally accepted treatment planning objectives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain

Treatment: A transforaminal epidural steroid injection

The insurer denied coverage for a transforaminal epidural steroid injection

The denial is overturned 

This patient has chronic low back pain with radicular symptoms. Magnetic resonance imaging (MRI) showed lumbar (L)4-L5 broad posterior disc bulge and L5-sacral (S)1 posterior central disc herniation with annular tear. Per the office visit note with the Pain Management specialist the patient reports minimal relief with conservative therapy. She has had 3 prior epidural steroid injections for pain. A transforaminal epidural steroid injection (TFESI) to deliver medication closer to the nerve root and anterior epidural space at L5-S1 is requested.

Murthy et al (1) studied repeat epidural steroid injections; they found a slight cumulative effect over time:

"This study demonstrates that patients with recent onset of pain can anticipate recovery of benefit with repeated TFESI and some cumulative effect. Patients with more chronic pain may see a decrease of benefit with repeated injections. When the response to an index injection is positive but incomplete, early reinjection can yield cumulative benefit; this effect is greater in patients with a shorter duration of pain at the index injection. The decision to perform repeat TFESI remains dependent on the response to the initial injection and the patient's clinical scenario, including features such as the degree of neural compression, which may predict long-term response."

Similarly, Joswig et al (2) have found that repeat salvage injections are efficacious:

"Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection."

Additional pain injections are considered medically reasonable and necessary for this patient.

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

The insurer's denial of coverage for additional pain injections is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Tegsedi. 
The denial is overturned.

The patient is a male with a mutation in the transthyretin (TTR) gene leading to the diagnosis of hereditary ATTR amyloidosis (PN-hATTR). The patient has symptoms of peripheral neuropathy, including painful dysesthesia and weakness, and cardiomyopathy. The patient is prescribed Tegsedi and Vyndamax. Tegsedi was denied by the plan because the patient is also treated with Vyndamax. The provider appealed the determination.
The subject under review is the medical necessity for the treatment with Tegsedi.

The health plan's determination is overturned.

The requested Tegsedi is medically necessary for this patient. The drug is an antisense oligonucleotide medication used for the treatment of nerve damage in adults with hereditary transthyretin-mediated amyloidosis. The patient has an established diagnosis by a geneticist. The patient has signs and symptoms of peripheral neuropathy. The patient has been treated with the medication with improved neuropathic pain symptoms based on a standardized scoring tool.
The drug was denied because the patient is on a medication to prevent heart damage due to the same genetic condition. However, the requested medication Tegsedi is only Food and Drug Administration (FDA) approved for nerve damage and it is not FDA approved to protect against cardiomyopathy. Vyndamax is not FDA approved for treatment of neuropathy. As such, the plan has required the patient to choose between a medication to treat neuropathy or to prevent heart disease.
The drugs have a different mechanism of action and there is no known interaction. There is no medication reason why the patient cannot continue treatment with Tegsedi. It is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Multiple Sclerosis
Treatment: Home health Care
The health plan denied the requested personal care hours as not medically necessary. The health plan determination is overturned.

The patient is a male with past medical history significant for multiple sclerosis. He has had progressive physical and cognitive decline secondary to multiple sclerosis. The patient has been currently approved for 52 hours a week of services.
At issue is the medical necessity for the requested health service for a Personal Care Aide (PCA) Level 2: Live-in per diem: 24 hours per day - 7 days per week.

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

Yes, the requested health service is medically necessary for this patient. Additional PCA services are medically necessary for the patient's declining health condition.
The Uniform Assessment System (UAS) State of New York were reviewed. These assessments state that the patient requires maximal to total assistance for almost all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Between the 2 reports it was noted that the patient did have a functional decline and an inability to transfer independently in bed and to wheelchair, along with transferring from the wheelchair to toilet. It was noted that the patient's physical ability has declined within the last 90 days.
An advocacy report/appeal requests additional services for 24-hour personal care services due to increased needs, especially during the overnight hours for toileting assistance, transfer, and ambulation.
Attending physician statements recommend 24-hour care, secondary to the patient's advancing symptoms of multiple sclerosis. 
I recommend overturning the decision based upon the following rationale. The patient did have a decline in his health based upon documentation from the Uniform Assessment System (UAS) assessments, specifically for transfers and ambulation with his wheelchair. The patient is unable to transfer independently from the bed to his wheelchair or from the wheelchair to the bathroom. It is also noted that the patient cannot functionally operate the wheelchair independently by himself. This leaves him an extended period time when aide services are not available. I think the time between the aide coming and leaving him alone for 16 hours a day where he cannot toilet or transfer independently poses a threat to his health, specifically for unscheduled tasks such as transfers and toileting. I am recommending granting additional services for 24-hours a day, 7 days per week, live-in services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis, urinary retention and incontinence
Treatment: Personal Care Aide Service - 7 Days a Week 2-12 Hours a Day (Split Shift)
The insurer denied the Personal Care Aide Service - 7 Days a Week 2-12 Hours a Day (Split Shift)
The denial is overturned

The patient is a female who has history of multiple sclerosis, urinary retention and incontinence. She is requesting home care services, seven days a week, two-12 Hours a Day (Split Shift) and is appealing reduction in home care services to seven days per week, live-in.

Yes, the proposed treatment, personal care aide services seven days a week, two-12 Hours a Day (Split Shift), is medically necessary.
The patient has history of multiple sclerosis, coronary artery disease (CAD), hypertension, hyperlipidemia and diabetes mellitus. She lives alone and is wheelchair bound. The patient's clinical condition has significantly deteriorated. She requires assistance with activities of daily living (ADLs) including self-care, dressing, bathing and reminders to take her medications. The patient needs repositioning every two to three hours during day time and night time. The patient needs constant supervision at home and needs split shifts (12 x 2) for seven days a week to ensure safety at home.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient needs repositioning every two to three hours, both days and nights. The patient will need extended hours of home care services.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening.
The insurer denied Oncotype DX Prostate. 
The denial is upheld. 

The patient at time with newly diagnosed prostate cancer. He has clinical t1c, Gleason grade Group 1 disease. This is a low-risk cancer per National Comprehensive Cancer Network (NCCN) criteria. Oncotype DX testing was ordered.
At issue is whether Oncotype DX Prostate is likely to be more beneficial than any standard treatment or treatments for the patient's disease.

The health plan's determination is upheld in whole.

The proposed health service or treatment Oncotype DX Prostate is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Current guidelines of the NCCN and American Society of Clinical Oncology (ASCO) do not endorse this testing for this clinical problem. ASCO notes, "With various degrees of value and validation, multiple biomarkers have been shown to refine risk stratification and can be considered for select men to improve management decisions. There is a paucity of prospective studies assessing short- and long-term outcomes of patients when these markers are integrated into clinical decision making. Tissue-based molecular biomarkers (evaluating the sample with the highest volume of the highest Gleason pattern) may improve risk stratification when added to standard clinical parameters, but the Expert Panel endorses their use only in situations in which the assay results, when considered as a whole with routine clinical factors, are likely to affect a clinical decision. These assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes-for example, quality of life, need for treatment, or survival."
In addition, the American Urological Association (AUA) guidelines note the test is one of several biomarkers not found to be beneficial in patients considered for active surveillance.
Therefore, the proposed service Oncotype DX Prostate is not likely to be more beneficial than any standard treatment or treatments for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening.
The insurer denied Oncotype DX Prostate. 
The denial is upheld. 

At the time of presentation, this patient, with prostate cancer had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 2 of 14 cores. The clinical stage was T1c. The prostate-specific antigen (PSA) was less than (<) 10.
At issue is whether the Oncotype DX Prostate is likely to be more beneficial than any standard treatment or treatments for the patient's disease.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

The proposed health service or treatment of Oncotype DX Prostate is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Per American Urological Association (AUA) Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)." Guideline Statement 32, "Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)."
This patient has a low-risk prostate cancer. Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test. National Comprehensive Cancer Network (NCCN) Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." "...ny of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."
Therefore, the proposed health service of Oncotype DX Prostate is not likely to be more beneficial than any standard treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; Dyspnea. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a woman with metastatic breast cancer, chemotherapy-induced cardiomyopathy with an ejection fraction of 40 to 50%, and chronic hypoxic respiratory failure on baseline oxygen supplementation, who presented to the hospital with worsening dyspnea on exertion as well as worsening left hip pain. The patient complains of a dry cough but no fevers or chills. She also denied headaches or vision changes, sore throat, or rhinorrhea. Vital signs included a blood pressure of 111/72, respirations of 22, pulse oximetry of 97%, and temperature of 36.9 C. Treatment medications at home include anticoagulation with Xarelto secondary to a history of pulmonary embolus and 40 milligrams (mg) of Lasix daily. 

The Inpatient Hospital Admission for the dates in question was not medically necessary for this patient. 

The patient presented with a combination of heart failure and pneumonia per the imaging studies. The hospital course was complicated by benzodiazepine withdrawal causing delirium, extending the typical length of stay of 5 days inpatient stay to 8 days to achieve stability. By the dates in question, the patient is on baseline oxygen requirement and has no signs of ongoing infection, normal white blood cell count, normal temperatures, stable vital signs, and no hemodynamic instability. The patient is tolerating oral medications and oral diet and can stay hydrated. The medical documentation does not support a worsening of the patient's condition to warrant an additional 17-day stay in the hospital under the inpatient level of care. Interventional radiology biopsy of the L (lumbar) 1 lesion can be performed at a lower level of care. There is no documentation of severe uncontrolled pain, the imaging is negative for spinal cord compression, and there is no indication for surgical decompression surgery. The medical literature is clear and supportive of a lower level of care for the dates in question.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Open margins
Treatment: White Glass With Gold Content Crown, Tooth 8
The insurer denied the White Glass With Gold Content Crown, Tooth 8
The denial is overturned.

The patient is a female. The request is for dental services for a white glass with gold content crown on tooth # (number) 8.

Per the provider's dental appeal summary, tooth #8 presents with open margins and the crown is 20 years old. The health plan denied coverage of the claim, because tooth #8 has an existing crown and the x-ray does not show any decay under the crown.

Yes, the requested crown replacement on tooth #8 is medically necessary.
Per the provider's dental clinical diagnosis, and as evident on the X-ray, there are open margins on the 20-year-old crown. There are areas of radiolucency on the mesial and distal aspects of tooth # 8; visible on the x-ray submitted. This would indicate that the margins of this crown are open and have been compromised and warrant replacing.

No, the health plan did not act reasonably, with sound judgement and in the best interest of the patient.
Open margins give rise to leakage and recurrent decay under and around the crown. If the crown is not replaced, the leakage over time will give rise to decay and compromise the integrity of the tooth structure under the crown. This will lead to eventual failure of the crown and possible tooth loss if the decay is substantial and cannot be restored.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Penile squamous cell cancer.

Treatment: Long term custodial care.

The insurer denied coverage for long term custodial care.

The denial is upheld.

This is patient was admitted with altered mental status and fever, most recently. His history is notable for penile squamous cell cancer. He is receiving opioids for somatic and neuropathic chronic pains. He has local wound care needs. The member is now afebrile and stable. He is able to perform basic mobility and functional transfers.

"In the United States, we are blessed with many options for postacute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports." (Mayer, R. S.. et al. 2020)

"Skilled nursing facility (SNF) care is health care given when you need skilled nursing or therapy staff to treat, manage, observe, and evaluate your care. Examples of SNF care include intravenous injections and physical therapy." (Centers for Medicare & Medicaid Services, 2019)  

There is no indication this member has any significant activities of daily living (ADLs) and mobility needs which are sufficient to justify a long-term care home at this time. Long term custodial care is not considered medically necessary for this patient. The was no documentation demonstrating the patient's requirement for the requested level of care. Based on the review of the available documentation, the requested services are not medically necessary, at this time.

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

The insurer's denial of coverage for long term custodial care is upheld. Medical Necessity is not substantiated.