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

Diagnosis: Left knee pain.
Treatment: Magnetic resonance imaging (MRI) of the left knee.
The insurer denied: Magnetic resonance imaging (MRI) of the left knee.
The denial is upheld.

The patient is an adult female. There is a note from the patient stating the physician told her to get a magnetic resonance image of her knee. The physician did not tell the patient to do exercises or physical therapy. There is a letter from the health plan stating the request was not medically necessary. The reason for the denial is that the notes provided do not support the National Imaging Associates, Inc (NIA) clinical guideline 057-4 for lower extremity magnetic resonance image (MRI). The guidelines are provided for review.
Per the Office Visit note, the patient came in for the left knee. The patient's injury was two months prior when she was rock climbing and the knee popped out of place. She had a previous injury in karate. The patient has been going to physical therapy. Exam of the knee showed no effusion. There was zero to 140 degrees of flexion. There was no anterior-posterior drawer. There was a negative Lachman's, no pivot, and no joint line tenderness. Magnetic resonance image shows a discoid lateral meniscus without a tear. Intact cruciate collateral ligaments. 
Per Urgent Care Visit, the patient presented with left knee pain; her kneecap popped one month ago and was not improving. There was no giving out or locking. The patient's exam showed no swelling, full range of motion, and no ligamentous instability.

The proposed treatment was not medically necessary.

The procedure is not in accordance with the generally accepted standards of medical practice. The generally accepted standards of medical practice would be a plain x-ray prior to the ordering of advanced imaging. There is no documentation of a plain x-ray for this patient. The procedure is not clinically appropriate, in terms of its type, frequency, extent, site and duration and considered effective for the patient's injury and pathology. The physical exam findings do not support the indications for advanced imaging.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Family history of other mental and behavioral disorders
Treatment: Genetic testing (for inherited disorders) 81405
The insurer denied: Genetic testing (for inherited disorders) 81405
The denial is overturned.

The patient is an adult female with a son, who has autism and abnormal genetic testing. There are no medical records provided, but there is an appeal letter submitted by the provider. 
There is also a pedigree provided. The provider requested genetic testing, which was previously denied, as the request was lacking a reasonable expectation, based on family history, pedigree analysis, risk factors and/or signs or symptoms that a genetically inherited condition exists, that the testing method was considered a proven method for the identification of a genetically linked disease and that the test results would influence decisions concerning disease treatment or prevention.

The proposed treatment is medically necessary.

Genetic testing of the parent is medically necessary as recommended by Kreiman and colleagues, as autism can be caused by inherited genes or de novo mutations. If genetic testing finds the same genetic defect in parent and child, then it is likely genetic, and then further genetic testing may be appropriate. Furthermore, management would also vary pending the results of the genetic testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypothyroidism
Treatment: Cytomel
The insurer denied Cytomel.
The denial is upheld.

The patient is an adult female with hypothyroidism. The request for Cytomel is under review. The prior request was denied coverage by the health plan, because "we could not identify reasons that you could not use the alternative, preferred drug Iiothyronine sodium tablets, Armor Thyroid tablets, Ievo-t tablets, Ievothyroxine tablets/capsules, Ievoxyl tablets, np thyroid tablets, Nature Thyroid tablets, Synthroid tablets, thyroid tablets, and unithyroid tablets (such as a contraindication or significant drug interaction)." The provider is appealing this determination.

The patient has continued fatigue and has felt better with the addition of Cyotmel in the past. The patient has had sensitivity to generic thyroid hormone in the past. She did not tolerate generic levothyroxine. Brand name Synthroid has worked well to control her thyroid hormone and kept levels stable.

The requested Cytomel is not medically necessary.

This request is for Cytomel for the treatment of hypothyroidism. The formulary alternatives include the generic form of liothyronine, which is expected to be equally safe and effective in this clinical situation as compared to Cytomel. The patient had a sensitivity to generic levothyroxine, which is not a contraindication to the use of generic liothyronine. Therefore, no, the requested Cytomel is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Treatment: Emgality
The insurer denied Emgality.
The health plan's determination is upheld.

The patient is a female with a diagnosis of migraines. The patient is reported to have three monthly headaches that respond to Ubrelvy.
An appeal letter states that the patient is of child bearing age and has asthma, which are not Food and Drug Administration (FDA) listed contraindications to all available non calcitonin gene-related peptide (CGRP) migraine prophylactic agents.
Another appeal letter states that the patient has failed Doxycycline, Furosemide, Levaquin, Meclizine, Metformin, Rizatriptan and Ketorolac, which are not generally accepted as proven migraine prophylactic agents.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The submitted medical records do not establish a medical necessity for Emgality. The patient is reported to have very low headache frequency, with a great response to Ubrelvy, and therefore, prophylactic agents would not usually be indicated.
The patient's medical records do not document that proper trials of standard migraine prophylactic agents have failed at standard doses, for 8 weeks or longer. As discussed above, there are no FDA listed contraindications to all available formulary agents documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory distress

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld 

This child has a history of wheezing from a respiratory syncytial virus (RSV) infection. The patient was sick with several days of a cough and an upper respiratory infection. On the day prior to admission, the patient developed fever and an increased respiratory rate. The patient's mother administered 3 doses of albuterol in the home and when the respiratory distress did not improve the mother brought the patient to the Emergency Room (ER) for an evaluation.

In the ER the patient was noted to be in mild respiratory distress with intercostal retractions. On physical exam the child had a barking cough with no stridor but mild acute distress with intercostal retractions. The patient was treated with racemic epinephrine and dexamethasone. A white blood count showed an elevated white blood count of 22,900 with a left shift and a respiratory viral panel was positive for rhino/enterovirus. A chest x-ray showed evidence of a subtle left lower lobe infiltrate. The patient was treated with ceftriaxone and azithromycin. Following treatment, the patient was noted to have one episode of an oxygen saturation of 91% which the medical record indicates resolved spontaneously in the ER. Based on the one episode of hypoxemia, the decision was made to admit the child to the hospital with a diagnosis of pneumonia and an asthma exacerbation for continued treatment with ceftriaxone, azithromycin, and albuterol every 4 hours. The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for an acute episode of a barking cough and mild respiratory distress. The child has a history of previous treatments for wheezing during an RSV infection. The medical record from the ER does not show that the attending ER physician was aware of the previous history of wheezing. When the patient had evidence of an elevated white blood count, mild retractions and one episode of hypoxemia the child was not given frequent albuterol treatments in the ER. It was not consistent with the standard of care to admit the child to the hospital with albuterol every four hours. The patient was stable enough to be safely discharged home with albuterol, and antibiotics with a follow up visit with the pediatrician in 24-48 hours. 

Based on the above, the insurer's denial must be upheld. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: diabetes mellitus, hypertension, and osteoarthritis

Treatment: Personal Care aide for 84 hours/week, 12 hours x 7 days; Personal care aide - Level 2

The insurer denied coverage for Personal Care aide for 84 hours/week, 12 hours x 7 days; Personal care aide - Level 2

The denial is upheld
 

This is a patient with a history of diabetes mellitus, hypertension, and osteoarthritis. According to the most recent Uniform Assessment System (UAS) the patient is alert and oriented x (times) 3, forgetful at times, able to make needs known, and direct care. The patient reported shortness of breath and weakness during daily activities. The patient requires maximal assistance for meal preparation, and ordinary housework. Extensive assistance is needed for managing medications, bathing, dressing lower body, walking, transferring to the toilet, and toilet use. No falls were reported in the last 90 days.

The medical records show that no acute nor unstable medical condition is present. Her recent visit to the physician was completed. She was reported to have "no new complaints and stable chronic conditions." Her physical examination was unremarkable with the exception of a Body Mass Index (BMI) over 40. 

The nursing assessments showed she was incontinent but able to change her own diaper. She was living at home with her husband and two children. She was able to contact Emergency Services if necessary.  She was able to perform several activities of daily living. The documentation provided by the physician was insufficient to support necessity. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care aide for 84 hours/week, 12 hours x 7 days; Personal care aide - Level 2 services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned

The patient presented with right lower quadrant (RLQ) abdominal pain. The patient was afebrile, and the vital signs were stable. The abdominal exam done during surgical consultation revealed rebound tenderness. The computerized axial tomography (CAT) scan showed a phlegmon in the right lower pelvis. This finding was felt to be due to a ruptured appendicitis. Intravenous (IV) antibiotics were given. It was decided that the patient should have non-operative management at this time. 

Clinical indications for admission in Milliman Care Guidelines (MCG) for Undiagnosed Abdominal Pain (MCG M-05) include having peritoneal signs. The surgeon found that this patient had abdominal rebound. 

Clinical indications for admission for acute appendicitis are listed in MCG (GRG:MG-GAS). Acute appendicitis with planned non-operative management is an indication for admission if the appendicitis is complicated by a phlegmon and the patient does not have systemic sepsis or require that the appendectomy be done at that time. 

This patient had rebound guarding and was diagnosed with a phlegmon that was felt to be due to a ruptured appendicitis. Giving a course of IV antibiotics was appropriate. The patient met MCG for admission both for Undiagnosed Abdominal Pain and Gastroenterology criteria for appendicitis. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the emergency department complaining of several hours of chest pain, dyspnea, blurred vision, "dizziness" and nausea. She had no significant past medical history. Her blood pressure was 105/73 millimeters of mercury (mmHg) with a heart rate of 50 beats/minute. She was afebrile. Her physical exam was unremarkable. Her electrocardiogram showed sinus bradycardia with sinus arrhythmia and was otherwise normal. Her high sensitivity troponin level was 171 nanograms per liter (ng/L). A chest computed tomography (CT) angiogram showed no evidence of pulmonary embolism. A head computed tomography (CT) scan showed no intracerebral pathology; there was possible paranasal sinus disease. The patient was treated with intravenous fluids, Reglan and magnesium and admitted to the hospital. Her troponin level rose to 218 ng/L. She remained in sinus rhythm with a minimum heart rate of 39 beats/minute during sleep. An echocardiogram showed normal left ventricular systolic function. The patient had no further symptoms and was discharged. At issue is the medical necessity for an inpatient admission.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This healthy female patient presented complaining of chest pain, dyspnea, blurred vision, "dizziness" and nausea. She had no cardiac risk factors. Her electrocardiogram showed sinus bradycardia, which is a common finding in healthy young people; there were no acute changes. While her serum troponin level was elevated, there was no significant delta troponin and thus, was not suggestive of acute coronary syndrome. Her HEART [history, electrocardiogram, age, risk factors, troponin] score suggested a low risk for major adverse cardiac events. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline
 for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: contraception.
Treatment: DEXA Scan (Dual Energy X-Ray Absorptiometry) Scan.
The insurer denied a DEXA (Dual Energy X-Ray Absorptiometry) Scan. 
The health plan's determination is overturned. 

The patient is a female who uses DepoProvera for contraception. She has been using DepoProvera for 7 years. At issue is the medical necessity to have DEXA (Dual Energy X-Ray Absorptiometry) scan performed to determine current bone mineral density due to the potential negative effects on bone mineral density by the Depo Provera.

Diagnostic Testing: DEXA (Dual Energy X-Ray Absorptiometry) Scan is medically necessary for this patient. Although DEXA scanning is not recommended for routine monitoring of a patient who has used DepoProvera during adolescence, there is significant risk of decreased bone mineral density and fracture while using DepoProvera, especially though adolescence. This patient has used DepoProvera continuously from age 15 to 22 and would like to continue its use. This is an exceptional case of use for 7 years, most of which were during a time that the patient should have been maximizing her bone mineral density. Thus, the test is medically necessary in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - Asthma.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied Nucala as not medically necessary. 
The health plan's determination is upheld.

The patient is a male who suffers from severe persistent asthma and eosinophilic granulomatosis with polyangiitis (EGPA). The provider is requesting the coverage of Nucala. The patient is on high dose Advair and Spiriva. The patient had an eosinophils count of 900-1200. The patient had frequent exacerbations requiring systemic steroids. His pulmonary function test (PFT) showed a forced expiratory volume (FEV1) less than 80%. The patient's symptoms improved while on the Nucala. The patient is also on Dupixent every 2 weeks.
At issue is the medical necessity of the requested health service/treatment of Nucala.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Nucala is not medically necessary for this patient. Nucala (mepolizumab) has been approved by the United States Food and Drug Administration (FDA) for add-on, maintenance treatment of severe asthma in patients who are age 12 or older and have an eosinophilic phenotype. The Nucala was also approved for the treatment of EGPA. Mepolizumab proved to be an efficacious treatment for eosinophilic granulomatosis with polyangiitis (EGPA) at a dose of 300 milligrams (mg) every 4 weeks. Complete response to treatment with Nucala was defined in clinical trials as no disease activity (Birmingham Vasculitis Activity Score [BVAS] of 0) and a prednisolone or prednisone dose (or equivalent) of less than or equal to 4 mg/day.
This patient suffers from asthma and EGPA. The patient has a high eosinophils count. The patient is on Advair and Spiriva in addition to Dupixent. There is no evidence that the patient EGPA is under good control with BVAS of 0.
On the other hand, there are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long-term efficacy and safety of combination of Dupixent and Nucala over Nucala or Dupixent used as monotherapy for the treatment of this patient's medical condition. There is also no high-quality literature showing an improvement in health outcomes with the use of combination of Dupixent and Nucala over Nucala or Dupixent used as monotherapy for this patient's condition.
Therefore, the requested health service/treatment Nucala is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dermatochalasis. 
Treatment: Blepharoplasty. 

The insurer denied blepharoplasty. The health plan's determination is upheld. 

The patient is a female with dermatochalasis for whom coverage of blepharoplasty is the subject of review. 

Blepharoplasty (Surgical Procedure on Eyelids) is medically necessary for this patient.
According to general standards of practice supported in the peer reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional/reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes. Typically, patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin. Photos should be consistent with visual field testing. In this case, the patient's eyelids reportedly impact driving. While marginal reflex distances are reported as 2 mm (millimeters), the photos provided do not support a marginal reflex distance of 2 mm or correlate with the visual field restriction described. Therefore, the medical necessity of bilateral upper eyelid blepharoplasty is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain injury
Treatment: Continued Acute Rehabilitation Care 
The insurer denied continued acute rehabilitation care.
The health plan's determination is upheld. 

The patient is a male with anxiety, attention deficit hyperactivity disorder (ADHD), hyperlipidemia, and tetrahydrocannabinol (THC) use who was found unresponsive. Emergency Medical Services (EMS) evaluated him and noted that he was in ventricular fibrillation. He was shocked four times at the scene and intubated. After arrival in the emergency department, he was evaluated and diagnosed with an myocardial infarction (MI). He received treatment with two cardiac stents in the Cath lab. He was diagnosed with anoxic brain injury following the cardiac arrest and admitted. 

The requested continued acute rehabilitation care is not medically necessary for this patient. The provider stated that the patient was fully dependent for care. He could not communicate his wants and needs, coordinate his finances, or sign for release of his medical records. He was not able to participate in intensive therapy for a minimum of 15 hours per week, was not showing measurable improvement in functioning, was not making progress in physical therapy (PT), occupational therapy (OT), and/or Speech Language Pathologist (SLP), and other care needs were not stable of improving. Continued stay at the Acute Rehabilitation level of care is not medically necessary. Other forms of care such as Skilled Nursing Facility or Home Care would be appropriate. As of the date in question, the patient could be treated at a lower level of care such as Skilled Nursing Facility (SNF) or home care. He was ambulating with a walker and required supervision for bathing and grooming. He was medically stable and did not require physician visits several times per week. He did not require 3 hours of therapy per day 5 days per week. The Milliman Care Guidelines (MCG) do not consider continued acute rehabilitation medically necessary for this patient. [1]