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

Diagnosis: Obstructive Sleep Apnea
Treatment: Durable Medical Equipment (DME) (E0486 Oral device/appliance cusfab)
The insurer denied coverage for DME (E0486 Oral device/appliance cusfab).
The denial is overturned.

The patient presented to the physician for recommendation on management of long-standing obstructive sleep apnea. The physician recommended oral appliance therapy. The insurer has denied oral appliance therapy for the patient, stating that the documentation provided and the clinical findings offered do not support or meet their medical necessity criteria. There is no documentation that Continuous Positive Airway Pressure (CPAP) was attempted and failed due to lack of tolerance. The patient's mother is appealing the denial on behalf of the patient.

Based on the documentation provided, it is clear that the results of the patient's sleep study exhibit obstructive sleep apnea. Although CPAP therapy is considered the gold standard treatment for this condition, other therapies such as oral appliance therapy are accepted treatment modalities and approved by the Food and Drug Administration (FDA) in those cases in which CPAP is unable to be tolerated or no longer effective. Peer reviewed literature indicates that an oral appliance is an effective treatment for obstructive sleep apnea. Further, this patient does fulfill Milliman Care Guidelines criteria for oral appliance therapy. As such, oral appliance therapy is considered medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for durable medical equipment (E0486 Oral device/appliance cusfab) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld. 

The patient is a male with past medical history of anxiety disorder, chronic back pain, depression, polysubstance abuse (crack cocaine and heroin), and mood disorder who presented to the emergency department with complaints of pain and swelling of his left third finger.

His vitals on presentation included: Temperature 98.8 F (Fahrenheit), Blood Pressure 171/89, Pulse 77, Respiratory Rate 18, oxygen (O2) saturation 100% on Room Air. Laboratory results included the following: WBC (white blood cell count)-8.97, HGB (hemoglobin)-13.6, HCT (hematocrit)-39.2, creatinine-0.84. 

Patient was started empirically on intravenous antibiotics (vancomycin and ceftriaxone) for hand cellulitis. X-ray of the hand showed soft tissue swelling without any other abnormalities. Computed tomography (CT) scan of the hand soft tissue swelling involving 3rd finger possibly representing a collection or mass. Hand Surgery evaluated patient and performed an incision & drainage procedure. Patient remained afebrile, hemodynamically stable, and clinically improved. He left hospital, signing out against medical advice (AMA).

According to documentation, patient was admitted with a left-hand finger infection. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory findings including a normal WBC. There was no evidence of a disseminated infection, he was able to tolerate oral intake. Based on these findings, patient did not meet criteria for acute care hospitalization. Patient met criteria for observation level of management.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient presented to the emergency room with complaints of left sided numbness. The patient denied tingling. The sensations initially started in the scalp and then involved the face and arm. The patient had no motor weakness. She had no walking or coordination impairment. She was admitted to the hospital and various studies such as a computed tomography (CT) scan of the head, magnetic resonance imaging (MRI) of the brain, and MRI of the cervical spine were ordered. The studies did not show any acute abnormalities. The patient did not have any vital signs or laboratory studies that showed any significant abnormalities. The patient was discharged with outpatient follow up. It was suggested that there may be no neurologic etiology and the symptoms could be functional. 

At issue is the medical necessity of an inpatient stay. 
The requested health service/treatment of inpatient stay was not medically necessary for this patient. 
The patient presented to the emergency room with non-disabling symptoms of left scalp, face, and arm numbness. The patient had no functional impairment. There was no weakness or difficulty walking. Rather than being referred to an outpatient clinic, the patient was admitted to the hospital as an inpatient. In the hospital, the patient underwent a variety of negative studies including various laboratory work, a CT scan of the head, MRI of the brain, and MRI of the cervical spine. None of these studies showed an etiology for the patient's left-sided numbness. Given that the only significant diagnostic studies that were performed included magnetic resonance studies, the stay was prolonged. There is no reason that the studies could not have been performed at a lower level of care. The patient did not have complex nursing or rehabilitation needs. The patient did not have significant vital sign or laboratory abnormalities that required monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis, Loculated Abscess. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient is a male with a past medical history significant for cholangitis, status post laparoscopic cholecystectomy, cecostomy tube, and abdominal abscess, who presented to the emergency room with complaints of pain and erythema on the abdomen at site of Jackson-Pratt (JP) drain. Vitals on presentation included a temperature 98.5 Fahrenheit, blood pressure 116/77, pulse 74, respiratory rate 18, and oxygen (O2) saturation 98% (percent) on room air. Laboratory results included white blood cell (WBC) count 8.41, hemoglobin 12.6, hematocrit 39.4, creatinine 0.48, glucose 94. 

The patient was started empirically on intravenous (IV) fluids and antibiotics (Zosyn) for possible abdominal wall infection. Computed tomography (CT) scan showed no definite fluid collection but did show inflammatory lesion/cellulitis. He underwent a bedside incision and drainage procedure. General Surgery consulted. The patient underwent exploratory laparoscopy with drainage of loculated abscess. Daily wound packing for superficial right flank wound was completed. He remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management on oral antibiotics (Augmentin). 

According to documentation, the patient presented with abdominal pain and cellulitis from a previous JP drainage site. Although the patient was afebrile and hemodynamically stable, he was a high-risk for infectious complications due to recent surgical intervention. Hospital admission was medically necessary for administration of IV antibiotics and diagnostic surgical interventions (incision & drainage, as well as exploratory laparoscopy with drainage of loculated abscess). 

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign Prostatic Hyperplasia
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient hospital stay.
The denial is upheld. 

Benign prostatic hyperplasia (BPH) is a common condition affecting men. It can lead to lower urinary tract symptoms (LUTS) such as urgency, nocturia, frequency, dysuria, difficulty emptying the bladder, difficulty initiating micturition, and interrupted stream during micturition. Medication is the first line of treatment for BPH. Standard of care includes 5-alpha-reductase inhibitors or alpha-blockers. Surgical management is indicated for patients with persistent symptoms despite medical management. Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for BPH. 

Per clinical documentation, the patient has a history of BPH with high-grade obstruction and urinary retention. The patient presented electively for a TURP. There were no reported complications. Postoperative lab values were within normal limits. The patient was discharged the following day within 24 hours. Milliman Care Guidelines (MCG) indicate that the goal length of stay for a TURP is ambulatory. Inpatient hospital admission is indicated for complications of the procedure or care of comorbidities. Per provided clinical documentation, the health plan acted reasonably and within the best interest of the patient. The acute inpatient admission was not medically necessary. An observation stay would be more appropriate. 

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

Diagnosis: Osteoarthritis.
Treatment: Orthovisc.

The insurer denied: Orthovisc.  The denial is upheld.

The patient is an adult female who presented with right knee pain.  She was treated with physical therapy and medications. On exam, there is tenderness along the medial joint line and patella. There was crepitus noted. A magnetic resonance image (MRI) of the right knee showed a meniscal tear and cartilage wear. She was diagnosed with primary osteoarthritis. An Orthovisc injection was requested.

The proposed treatment is not medically necessary.

The patient has not tried and failed corticosteroid injections for the treatment of her knee osteoarthritis. This would be considered first line treatment for knee osteoarthritis (OA) after failure of medications and physical therapy. Corticosteroid injections are recommended prior to hyaluronic acid injections, such as Orthovisc, due to superior evidence of efficacy. The listed preference to avoid steroid injections due to family history of osteoporosis and asthma is not a true contraindication to their use. As such, the requested Orthovisc is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Migraine Headaches.
Treatment: Botox.
The insurer denied Botox.
The denial is upheld.

The patient is an adult female with chronic migraine without aura, not intractable, without status migrainosus. She was previously on Botox with improvement in her migraines. The provider wishes to continue Botox. The request was previously denied as patient had not tried at least three formulary alternatives. Formulary alternatives include Aimovig, Ajovy and Emgality.

The health plan should not cover the proposed treatment.

Although Botox is effective for chronic migraines, anti-CGRPs (anti-calcitonin gene-related peptides), which include the three formulary alternatives, are highly efficacious for migraine prevention. The American Headache Society has established an anti-CGRP guidelines and per guidelines, patient would be appropriate to try these medications. Furthermore, there is a paucity of data in the literature to suggest that Botox is superior to the formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic kidney disease.
Treatment:  Jardiance.

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

The patient is a male with colon cancer, hypertension, hyperlipidemia, and stage III chronic kidney disease with nephropathy. Jardiance was prescribed and is the subject of this review.

Jardiance is not medically necessary for this patient.

The patient does not have type II diabetes or heart failure. The drug was not prescribed to reduce the incidence of cardiovascular death in the setting of type II diabetes or heart failure. In summary, Jardiance is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing Teeth
Treatment: Partial Lower and Partial Upper Denture
The insurer denied the partial lower and partial upper denture.
The denial is overturned.

The patient is a female who presented to the office of her dental provider for evaluation and treatment of missing teeth in the maxilla and mandible. Included for review are previous letters of appeal and denial, clinical notes, full mouth panoramic radiographic image, one page of American Dental Association (ADA) claim forms, and health plan language.

In question is the medical necessity of the planned treatment of maxillary and mandibular partial dentures. Previous denials have been on the basis that in order for the patient to qualify, there must be less than eight back teeth that touch.

The health plan's determination is overturned.

The requested partial lower denture and partial upper denture is medically necessary for this patient. As the patient is missing teeth, the teeth require replacement. There is no scientific basis for the health plan argument that there needs to be less than 8 back teeth in contact before a partial denture is necessary; this is not based on scientific rationale. As the patient is missing teeth, they require tooth replacement. This is standard in dentistry. Not replacing the teeth will allow for tooth migration, both in mesial direction as well as in supra eruption, causing the patient to suffer from malocclusion as well as interfering in disclusion. Hence the treatment is necessary to prevent tooth migration and malocclusion.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Dental Problems/Other/Dental Needs, Tooth 14 - Amalgam Filling with Several Fractures

Treatment: Dental/Orthodontic Procedure/Dental Services: Olay Porcelain - Four or More Surfaces, Tooth 14

I uphold, in whole, the health plan's determination of medical necessity.


The patient is a female who presented to the office for the treatment of Onlay Porcelain - Four or More Surfaces, Tooth 14. Provided for review are letters of appeal and denial, multiple radiographic images of the tooth in question and the remainder of the dentition, health plan language, and a narrative from the provider's office.
In question is the medical necessity for the requested service/treatment of Dental Services: Onlay Porcelain - Four or More Surfaces, Tooth 14.


No, the requested health service/treatment of dental Services: Onlay Porcelain - Four or More Surfaces, Tooth 14 is not medically necessary for this patient.
There is nothing in the provided documentation to support the presence of a large previously existing restoration, failure of the previous restoration, nor any decay. Support for the medical necessity of the provided treatment is absent in this case. As there is no evidence of the medical necessity of the provided treatment, it cannot be said that the Onlay for tooth #14 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal Calculi
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient was admitted on for bilateral hydronephrosis secondary to renal calculi and was discharged in 24 hours.

Based on the limited records received for review the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. It should be noted that no records were provided for review from the admission. 

The denial is for inpatient services. The records submitted do not document the details of that inpatient stay thus the request for services is upheld.

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

Diagnosis: breast abscess.
Treatment: inpatient stay.
the insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is an infant who presented with right breast erythema and firmness. She was well until the night prior to presentation when she developed erythema of the right breast. The erythema worsened over time, so she was brought to her primary doctor who referred her to the emergency department for care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a neonate who presented with mastitis and a breast abscess. Young infants less than(<) 2 months of age require prompt initiation of parenteral treatment with these types of localized infections due to their immature immune systems and the risk of rapid spread and serious morbidity. Therefore, she required inpatient hospital admission for broad spectrum, intravenous antibiotics along with close monitoring while cultures were pending.
The decision making at the time of admission for this patient was consistent with her very young age, the presence of an infection that was worsening, and the need for prompt initiation of intravenous antibiotics along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria.
Treatment: Top Surgery.
The insurer denied: Top Surgery.
The denial is overturned.

The patient is an adolescent female-to-male transgender. He has been on testosterone and has been presenting as a boy for two years. He wears a breast binder. His mental health professional supports the plan for surgery to treat his gender dysphoria. His surgeon recommends top surgery.

The requested top surgery is medically necessary.

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" guidelines:
Criteria for Breast/Chest Surgery (One Referral) Criteria for mastectomy and creation of a male chest in FtM (female-to-male) patients:
1- Persistent, well-documented gender dysphoria;
2- Capacity to make a fully informed decision and to consent for treatment;
3- Age of majority in a given country (if younger, follow the SOC [standard of care] for children and adolescents);
4- If significant medical or mental health concerns are present, they must be reasonably well controlled.
Hormone therapy is not a prerequisite.

Regarding chest surgery for adolescents, WPATH (World Professional Association for Transgender Health) guidelines are as follows: "Chest surgery in FtM [female-to-male] patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identity expression."
The patient meets these guidelines. He has well documented gender dysphoria and has the capacity to make an informed decision. He has been on hormone therapy for 18 months. Mental health concerns are managed by his therapist. His mental health professional is experienced in transgender care and has recommended the mastectomies. The standard of care for adolescent top surgery is met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preeclampsia
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This patient is an adult female who was sent for inpatient hospital admission 6 days after delivery, because of elevated blood pressure, elevated creatinine (1.03) and headache, for blood pressure monitoring and intravenous (IV) magnesium sulfate. There was no protein in her urine.

The patient has lupus and was maintained on Plaquenil. Blood pressure on admission included Systolic 120-132/Diastolic 78-85. Progress note the day after admission: Blood pressure 113/75, repeat creatinine was 0.8, the patient was doing well with no headache. She was discharged.

This patient presented 6 days after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery. The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:

Systolic blood pressure greater than or equal to 140 millimeters of mercury (mmHg) or diastolic blood pressure greater than or equal to 90 mmHg, (CONDITION NOT MET) and

1) Proteinuria greater than or equal to 0.3 grams in a 24-hour urine specimen or protein: creatinine ratio greater than or equal to 0.3, (CONDITION NOT MET) or 2) Signs of end-organ dysfunction [platelet count < (less than) 100,000/microliter, serum creatinine > (greater than) 1.1 micrograms/deciliter or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration]. (CONDITION NOT MET)

This patient had minimal elevation in blood pressure. This patient did not have a diagnosis of preeclampsia. She had mildly elevated blood pressure and inpatient hospital admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plantar fasciitis
Treatment: Custom Shoe Inserts (L3000 x 2)
The insurer denied coverage for custom shoe inserts (L3000 x 2).
The denial is overturned.

The patient has an ongoing diagnosis of plantar fasciitis previously treated with custom orthotics. The patient's orthotics have worn out and they need new orthotics; however, these have been denied and deemed not medically necessary. From the notes made available, the patient has tried modified activity and has been stretching with no relief. There is extensive research on the use of custom orthotics for patients with chronic plantar fasciitis. "Custom semirigid foot orthotics may significantly reduce pain experienced during walking and may reduce more global measures of pain and disability for patients with chronic plantar fasciitis." (1) Studies comparing prefabricated orthotics and custom orthotics have shown that the latter is a better course of treatment in the treatment of heel pain. One study showed a "5.6-fold greater improvement" (2) in patients utilizing custom orthotics. As such, the patient would benefit from the use of these custom orthotics.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for custom shoe inserts (L3000 x 2) is substantiated.