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


 
Diagnosis: Bladder Cancer.

Treatment: computed tomography (CT) billing code 74177.

The insurer denied coverage for computed tomography (CT) billing code 74177.

The denial is overturned.

This is a patient who is status-post radical cystectomy with conduit and supracervical hysterectomy. The patient had advanced disease with invasive, high-grade papillary urothelial carcinoma with extensive squamous differentiation (Stage IIIb) and the patient has been on adjunct nivolumab. The patient had a computed tomography (CT) scan, and it was denied by insurance as not medically necessary. They stated that follow-up imaging is supported once per 6 months for 2 years then once a year for 3 years. The patient's appeal is noted and read in detail. Per the patient's medical records (MR), the patient had a chest CT, positron emission testing (PET)/CT, and a repeat chest CT all of which revealed small, stable mediastinal and hilar lymph nodes, that did not meet size criteria for pathologic lymphadenopathy (LAD) but nodes were fluorodeoxyglucose (FDG) avid on repeat PET/CT, which favored metastatic in etiology. The patient was advised of the need for pulmonary evaluation for possible bronchoscopy, but the patient did not want to go for this evaluation yet and wanted short-term imaging follow-up, so a repeat CT was ordered. The CT scan ordered was a CT scan of the abdomen and pelvis with intravenous (IV) contrast and oral contrast. The most recent CT scan abdomen/pelvis was 9 months prior. It must be noted this patient is being followed for metastatic disease in the chest/abdomen/pelvis. Per the imaging guidelines, studies are supported every 6 months for 2 years, but the patient may have overlapping CT scans ordered. The last CT abdomen/pelvis was more than 6 months ago, so the CT abdomen/pelvis should be covered. 

Based on the above, the insurer's denial must be reversed. 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 computed tomography (CT) billing code 74177 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Developmental delay. 
Treatment: home health care. 
The insurer denied Consumer Directed Personal Assistance Services. 
The health plan's determination is upheld. 

This is a young female patient with a history of global developmental delay, speech delay, behavior concern, and hypotonia. The patient lives with her mother and 4 siblings under the age of 12. The patient's mother requested Consumer Directed Personal Assistance Services (CDPAS). 
An in-person Uniform Assessment System (UAS) was completed. Per the UAS, the patient's mother reports that she is often restless, can be resistant to care, aggressive toward others, and requires frequent redirection to participate. Her mother states that she is unable to follow simple commands due to cognitive impairment. 

Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance (CDPAS) is not medically necessary. 
Based on the recent Uniform Assessment System (UAS), the patient's ability to perform daily activities is at a level that is expected of a child of her age. Her behaviors of being restless, requiring frequent redirection, and having difficulty following commands are also typical of a child her age. The patient does not have any specific daily needs related to a medical condition. She does not require assistance with any daily activities outside of the normal assistance required by a child of this age that is usually provided by a child's parents. CDPAS is not intended to provide childcare or replace the basic responsibilities of the parent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:	Hyperglycemia	

Treatment: inpatient treatment

The insurer denied admission

The denial is reversed

This is an adolescent patient diagnosed with uncontrolled type II diabetes and hyperglycemia. The request is for coverage of inpatient admission. The patient presented to the emergency room (ER) with a 1-day history of abdominal pain that was sudden and non-radiating and nausea and vomiting (4 episodes). The patient was non-compliant with their medications. The patient's pain is localized to the epigastric region and is rated 10/10. The patient notes that they had ongoing polydipsia. On examination, the patient had vaginal discharge. 

Vital signs on presentation included blood pressure (BP) 122/80, respiratory rate (RR) 20, and pulse (P) 101. Labs included: glucose 438, pH (Pulmonary hypertension) 7.35, bicarbonate (HCO3) 18.9 (low), sodium 132  (hyponatremia), magnesium 1.8, white blood cells (WBC) 13.6, potassium 4.3, calcium 5.2, chloride 103, lactate 1.1, blood urea nitrogen (BUN) 18, creatinine 0.5, anion gap 17.4 (elevated), carbon dioxide (CO2) 18 (low), estimated glomerular filtration rate (eGFR) 140.2, Beta hydroxybutyrate 1.95, phosphorus 4, alkaline phosphatase 85, partial carbon dioxide (pCO2) 34.4, and partial oxygen (pO2) 64.9.

The patient was treated with intravenous (IV) fluids, potassium, Zofran, and insulin. The patient had persistent hyperglycemia of 343 and abdominal pain. Urinalysis revealed: WBC 11/20, red blood cells (RBC) 11/20, and bacteria many.

The patient required acute inpatient care for the management of abdominal pain, vomiting, medication noncompliance, hyperglycemia, acidosis, leukocytosis, hyponatremia, and hypomagnesemia.

Hospitalization for diabetic ketoacidosis (DKA) is universally medically necessary (1-9). Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require intensive care unit (ICU) level care (1), (3), (4), (5) until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring intensive care unit (ICU) level care (10),(11).  Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with every (q) 1 hours (h) blood draws and nursing rules.

The patient was admitted because they had diabetic ketoacidosis.

The patient met the criteria for the diagnosis of mild DKA based on a pH of 7.35 with an elevated anion gap of 17.5 and a low HCO3 18.9 and an elevated Beta hydroxybutyrate of 1.95. The patient had persistent hyperglycemia with nausea and vomiting and severe abdominal pain as well as hyponatremia and hypomagnesemia. The patient could not have been safely discharged from the emergency room and could not have been cared for in observation given the multiple comorbidities.

Admission is consistent with generally accepted standards of medical practice.

Based on the above, the insurer's denial must be reversed. 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 an inpatient admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Code 55880 ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) including ultrasound guidance. 
The insurer denied Code 55880 ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) including ultrasound guidance. 
The determination is upheld. 

This is a male patient with unfavorable intermediate risk prostate cancer. He had a negative metastatic workup. Focal HIFU therapy was recommended. At issue is whether ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The requested procedure is not as likely to produce the same outcome as standard therapy. It is not endorsed by current guidelines as standard of care for unfavorable intermediate risk disease. The American Urological Association (AUA) states, "For patients with unfavorable intermediate- or high-risk prostate cancer and estimated life expectancy greater than 10 years, clinicians should offer a choice between radical prostatectomy or radiation therapy plus androgen deprivation therapy (ADT). Clinicians should inform patients with intermediate-risk prostate cancer considering whole gland or focal ablation that there are a lack of high-quality data comparing ablation outcomes to radiation therapy, surgery, and active surveillance."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Code 55880 ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) including ultrasound guidance. 
The insurer denied Code 55880 ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) including ultrasound guidance. 
The determination is upheld. 

This is a male patient with an intermediate risk prostate cancer who has requested coverage for prostate high intensity-focused ultrasound (HIFU), including ultrasound guidance. The patient's prostate-specific antigen (PSA) was 10.09. The Gleason score was 3+4=7. Five of 13 cores were positive for malignancy. A prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) had no evidence of metastatic disease. At issue is whether ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The proposed health service or treatment ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This is a male patient with an intermediate risk prostate cancer. Per the American Urological Association (AUA) Guidelines, "12. For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. (Strong Recommendation; Evidence Level: Grade A) 
13. Clinicians should inform patients with intermediate-risk prostate cancer considering whole gland or focal ablation that there are a lack of high-quality data comparing ablation outcomes to radiation therapy, surgery, and active surveillance. (Expert Opinion)."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Code 55880 ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) including ultrasound guidance. 
The insurer denied Code 55880 ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) including ultrasound guidance. 
The determination is upheld. 

This is a male patient with 3+4=7 Gleason grade adenocarcinoma, prostate-specific antigen (PSA) 10.09, cT1c. A prostate-specific membrane antigen scan was negative. The request is for high intensity-focused ultrasound (HIFU). At issue is whether ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
There is insufficient evidence to suggest that the proposed health service or treatment ablation of malignant prostate tissue with HIFU is more beneficial than any standard treatment. 
Numerous ablative modalities, relying on differing energy sources/differing mechanisms of action, are currently available to patients with clinically localized prostate cancer (Hopstaken et al). Patient selection criteria in reported studies have varied widely as has treatment planning approach (eg, lesion-based focal therapy, hemi-ablation, whole-gland). The only properly powered randomized trial reported to date on prostate ablation was restricted to patients with low-risk prostate cancer and demonstrated that focal photodynamic therapy (PDT) lowered the likelihood of cancer progression and rates of surgery/radiation compared to active surveillance, at an expense of an increased likelihood of mild urinary or erectile dysfunction (Gill et al). However, PDT is not approved in the United States. Further, active surveillance is the preferred approach for patients with low-risk prostate cancer. 
Institutional, multi-site, and population-based studies have reported outcomes of various ablative therapies; however, with absence of randomization, non-standardized protocols, and insufficient follow-up, the role of ablative therapy in the management of clinically localized prostate cancer remains to be defined. Fortunately, randomized trials are ongoing and more are anticipated.
Appeal type: Medical necessity
Decision: Upheld

Dental
Dental treatment

Diagnosis: Dental issues
Treatment: Onlay on Tooth 29
The insurer denied Onlay on Tooth 29.
The health plan's determination is upheld. 

The patient is a female who presents for the treatment of tooth #29 with porcelain onlay. 

Based on the provided documentation, the Onlay on Tooth 29 is not medically necessary for this patient.
Based on the provided documentation, the tooth does not have the appearance of involved cusps nor decay to the extent to require the requested treatment and instead could have been treated with a direct restoration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature
Treatment: Genotropin
The insurer denied: Genotropin
The denial is upheld.

This case involves an adolescent male followed for short stature (height below first percentile). He had a normal endocrinology evaluation including normal initial blood work, a normal growth hormone stimulation test with peak growth hormone (GH) of 11.8, 3 months ago and normal magnetic resonance imaging (MRI) of the pituitary gland. His mid-parental height target is 66.5 inches placing his expected adult height between the 10th to 25th percentile. His most recent bone age was read as consistent with 10 years. Endocrinologist review states bone age is closest to 9 years and 6 months, giving him a 17-month delay in his growth plates compared to his chronological age. Pre-growth hormone treatment expected adult height is 5 feet and 5 inches based on documentation from the patient's endocrinologist. The patient's endocrinologist is seeking approval for growth hormone (Genotropin) for idiopathic short stature.

The requested health service is not medically necessary.

The patient's expected adult height is 5 feet and 5 inches according to his endocrinologist. However, although he is less than the first percentile now, this patient's expected adult height is normal for his genetic potential. Growth hormone is approved for idiopathic short stature by the United States Food and Drug Administration (FDA). In defining idiopathic short stature for the indication of recombinant human growth hormone (rhGH) treatment, the United States Food and Drug Administration uses a more stringent criterion of 2.25 standard deviations below the mean (i.e., the 1.2nd percentile) and a predicted adult height that is below the normal range; this corresponds to an adult height lower than 63 inches (160 centimeters) for males. This patient's expected adult height is above this and is normal for his genetic potential. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: nausea/vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female with a medical history of gastroesophageal reflux disease (GERD), morbid obesity status post laparoscopic sleeve gastrectomy, pre-diabetes, and hypertension. She presented to the emergency department with poor oral intake for 6 days, nausea, vomiting with any oral intake including water, chest pain, constipation, weakness, dizziness, near-syncope, chills, and fatigue. Vital signs were notable for rapid pulse of 110/minute. Physical examination was notable for ill appearance, pallor, and soft, non-distended abdomen with well-healed incisions, tenderness to light palpation in the right upper quadrant, epigastrium, and all of the lower abdomen.

The inpatient hospital admission was not medically necessary in this case. Although the patient presented with nausea, vomiting, and poor oral intake, she did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion. The presenting symptoms were consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease), gastric stenosis, or small bowel obstruction. However, imaging did not show any of these, or gastrointestinal leak, perforation, or other postoperative complications of sleeve gastrectomy, and the patient did not have evidence of bowel obstruction, peritonitis, abscess, fistula, sepsis, gastrointestinal bleeding, or other complications warranting inpatient level of care. Her symptoms improved with conservative therapy. She was anemic, but there was no active gastrointestinal bleeding. Additionally, although the patient had elevated liver enzymes on presentation, there was no evidence of acute liver failure, ascending cholangitis, hepatic abscess, or other complications which would require the inpatient level of care. All of the measures that were undertaken during the brief stay, including observation, monitoring, labs, imaging, and intravenous fluid administration, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foreign Body Ingestion
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This patient is a toddler female. She had foreign body ingestion (magnet pieces) and was hospitalized. A brief summary of her hospital stay notes that on day #1 the patient was seen in the 
emergency department. An emergency department note and admission history and physical indicates she was seen for foreign body swallowing. An X-ray showed three pieces in the abdomen, likely in the small intestine. Gastrointestinal (GI) was consulted, and the patient was sent to the operating room where one piece was removed from the stomach by endoscopy. Two pieces were still in the intestine. The patient was admitted for observation and monitoring. The treatment plan was serial abdominal X-ray. A progress note on day #2 stated the X-ray showed the pieces were moving in the intestine. She was clinically stable with no abdominal pain or vomiting. On day #3, a progress note stated the patient was doing well with no acute events. The X-ray 
showed the pieces moved to cecum, then to ascending colon. She was discharged home with outpatient X-ray.

The requested health service was not medically necessary.

Multiple magnet ingestion may cause severe consequences in children. Current guidelines and consensus recommend immediate endoscopic removal if still in stomach and inpatient observation and monitoring if in the small intestine (1-2). As documented in clinical notes, this patient went to the operating room and had one magnet piece removed from the stomach. The patient still had two magnets in the small intestine. The patient was admitted for observation and serial X-ray to monitor progression. For the duration of the stay, the patient was clinically stable and did not have any gastrointestinal symptoms. X-ray showed magnet progression to the colon. There were not any acute events or intervention. Thus, the requested acute inpatient care was not medically necessary. The requested health service could be achieved at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleepiness and snoring
Treatment: Mouthpiece to wear during sleep
The insurer denied mouthpiece to wear during sleep.
The determination is upheld. 

This is a female patient who was referred to the sleep lab to have a sleep study. The patient has been complaining of symptoms of sleep apnea including sleepiness and snoring. The patient had a nocturnal oximetry test that showed an oxygen desaturation index of 5.4. The patient has history of hypertension. The patient did not have an official home or in lab sleep study.
The patient refused the continuous positive airway pressure (CPAP). The provider is requesting the coverage of an oral appliance. The patient has no contraindication to the oral appliance. At issue is the medical necessity of a mouthpiece to wear during sleep.
The requested health service/treatment of mouthpiece to wear during sleep is not medically necessary for this patient.
Continuous positive airway pressure (CPAP) is the primary treatment for obstructive sleep apnea (OSA). According to national guidelines on the treatment of sleep apnea, CPAP is indicated for all patients with an apnea hypopnea index (AHI) of 5 to 15 events per hour if accompanied by symptoms of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, or documented cardiovascular diseases to include hypertension, ischemic heart disease, or stroke.
However, many patients are unable or unwilling to comply with this treatment. Oral appliances (mandibular advancement devices) are an alternative treatment for obstructive sleep apnea (OSA). Oral appliances are fitted by dentists and are designed to open and advance the mandible anteriorly during sleep with the goal of maintaining oropharynx patency.
Based on Milliman care guidelines, Oral appliance (mandibular advancement device) is indicated for obstructive sleep apnea (OSA) when there is evidence of obstructive sleep apnea and any one of the following:
-Patient is intolerant to CPAP.
-Patient refuses CPAP.
and
-Sufficient dentition to allow for retention of appliance
-No active periodontal disease or dental decay
-No active temporomandibular joint disorder
-No restriction in mandibular opening or protrusion
Based on the American Academy of Sleep Medicine published guidelines, in the absence of a contraindication, oral appliances are now indicated for use in patients with mild to moderate OSA who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, OR who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep-position change.
This patient has nocturnal oximetry that showed desaturation index of 5.4. The nocturnal oximetry is not considered a standard test to evaluate patient for symptoms of sleep apnea. The patient did not have a home sleep study or in lab sleep study that confirmed the presence of sleep apnea. Therefore, the oral appliance is not medically necessary.