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

Diagnosis: Takotsubo cardiomyopathy.
Treatment: Full Hospital Admission.
The insurer denied coverage for the Full Hospital Admission.
The denial is overturned. 

This is a female patient with a history of asthma, clostridium difficile (C. diff), hypertension, and high cholesterol. She presented to the emergency room (ER) with complaints of chest pain after watching her cat die. She developed substernal chest pain, which she described with a clenched fist. Her vital signs on admission include blood pressure (BP) 170/115, pulse 100, temperature 98.3, respirations 26, oxygen saturation 98% and body mass index (BMI) 22.30. On physical exam no abnormalities were noted. 

The physician's assessment was ST-elevation myocardial infarction (NSTEMI). The patient's admission diagnosis was listed as Takotsubo cardiomyopathy. The patient had a coronary angiogram which showed clean coronary arteries and ejection fraction of 25-30% with regional wall motion abnormalities. The impression was that this was consistent with Takotsubo cardiomyopathy and the plan included starting her on Coreg. 

Acute stress-induced (Takotsubo) cardiomyopathy has a dramatic clinical presentation, mimicking an acute myocardial infarction and is triggered by intense emotional or physical stress. The short-term and long-term outlook puts this new syndrome on a different perspective compared with recently held views. Current knowledge on susceptibility and predisposition already define distinctive characteristics of patients with Takotsubo compared with myocardial infarction. (1) Templin et al in a registry study of 1750 patients noted that these patients had a 21% rate of in-hospital complications, similar to that seen in patients with acute coronary syndrome. In addition, their left ventricular function was worse. 

This patient presented to the hospital with chest pain after an emotionally traumatic event. Her blood pressure and heart rate were elevated and she had slight elevation of her troponin level. She did have ST segment (the line on the electrocardiogram that begins with the end of the QRS complex and ends at the beginning of the T wave)changes on her electrocardiogram (EKG). Her clinical picture was consistent with Takotsubo cardiomyopathy. As noted a minority of patients have adverse events due to increased catecholamine stimulation. Because of this, it was necessary to admit the patient to the hospital. This hospitalization was necessary to make certain that this patient with a decreased ejection fraction, elevation of her troponin and ST segment changes on her EKG did not have any adverse events. 

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

The medical necessity for the Full Hospital Admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertriglyceridemia.
Treatment: Vascepa (Icosapent ethyl).
The insurer denied the Vascepa (Icosapent ethyl).
The denial is overturned. 

This is a female with type II diabetes, obesity, hyperlipidemia, and hypertriglyceridemia. She cannot tolerate fibrates. She tried and failed fish oil for three years. She is trying to conceive and she cannot take statin therapy. Her triglyceride level was 215 milligrams per deciliter (mg/dL). Request for Vascepa is under review.

Yes, the proposed Vascepa is medically necessary.

Vascepa is Food and Drug Administration (FDA)-indicated for the treatment of hypertriglyceridemia to reduce the risk of adverse cardiovascular events for patients with a pre-treatment triglyceride level of 150-499 mg/dL, and established cardiovascular disease or diabetes with two or more risk factors for developing cardiovascular disease when the medication will be used as an adjunct to maximally tolerated statin therapy. 

This patient has hypertriglyceridemia with a triglyceride level 215 milligrams per deciliter (mg/dL). She has type II diabetes and two additional risk factors for cardiovascular disease, hyperlipidemia and obesity. The prior request for Vascepa was denied as the patient is not taking a statin therapy. This patient is trying to conceive, and therefore statin therapy is contraindicated in her case. Vascepa is indicated to be used with maximally tolerated statin therapy. In this case, this patient is not able to take any statin therapy. The use of Vascepa without concomitant statin therapy is supported by the peer-reviewed literature [1]. Therefore, there is a medical exception in this case for the use of Vascepa without statin therapy. Without Vascepa, this patient will be at increased risk of long-term adverse cardiovascular events. Therefore, the proposed Vascepa is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 

Treatment: Implants (implant/abutment supported removable dentures) and attachments for dentures (semi-precision attachment) for teeth #s 4, 6, 12, 20, 22, 24, 27 and 29.

The insurer denied coverage for implants (implant/abutment supported removable dentures) and attachments for dentures (semi-precision attachment) for teeth #s 4, 6, 12, 20, 22, 24, 27 and 29.

The denial is overturned. 

This is a female patient who presented for dental evaluation complaining of inability to wear and function with removable partial dentures. The recommended treatment was for implant retained maxillary and mandibular removable dentures. The insurer has denied these services as not medically necessary, stating that these services are not covered and there is no documentation provided that indicated the patient cannot wear conventional prostheses.

Based on review of the documentation it appears that this patient is exhibiting decreased ability to function presumably with the existing full dentures, a commonplace occurrence due to ongoing resorption of the edentulous alveolar ridges. In this case a standard of care in dental practice would be the aforementioned recommended treatment. Peer reviewed literature supports implant retained dentures in this clinical circumstance to restore function. As this is the case, the implant retained dentures and associated services are deemed medically necessary.

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

The medical necessity for implants (implant/abutment supported removable dentures) and attachments for dentures (semi-precision attachment) for teeth #s 4, 6, 12, 20, 22, 24, 27 and 29 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent ventricular tachycardia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female with a past medical history significant for asthma, congenital heart disease, ventricular septal defect (VSD), status post (s/p) repair, bicuspid aortic valve and coarctation of aorta, status post prior repair, ventricular tachycardia, status post automatic implantable cardioverter defibrillator (AICD) and multiple prior ablations, AV nodal re-entry tachycardia (AVNRT), status post ablation, atrial fibrillation and flutter, status post ablation.  

The patient presented for an elective ablation of recurrent ventricular tachycardia. The patient underwent the planned procedure and had to be intubated for the ablation.  Post-procedurally, her course was complicated by hypotension, requiring intravenous (IV) pressor support with levophed and epinephrine.  She was weaned off and transferred to the coronary care unit (CCU) for monitoring. Anticoagulation was restarted post procedure, and patient was discharged home the next day with a plan for outpatient follow-up.

Yes, the proposed inpatient admission was medically necessary.
The proposed treatment was medically necessary.

This is a patient with a complex cardiac history, including congenital heart disease, prior surgical repair, and multiple ablations.  She presented for an electrophysiology procedure, involving transcatheter ablation of ventricular arrhythmia. The procedure required endotracheal intubation, and post procedure, use of intravenous pressor support was necessary due to hemodynamic compromise. The patient had an increased risk for bleeding complications due to chronic use of anticoagulation in the setting of atrial fibrillation. Given the comorbidities, as well as high risk procedure, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically appropriate in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/ Knee Problem/Pain. 
Treatment: Radiology Services/ Magnetic Resonance Imaging (MRI). 

The health plan denied the requested MRI as not medically necessary. 
The health plan's determination is overturned. 

This is a male who has been recommended for a left knee magnetic resonance imaging (MRI). A progress report  indicates the patient has had intermittent left knee pain since fifth grade. There is anterior discomfort and a giving out sensation. The patient never limps. The patient does not recall swelling. The pain comes and goes. The patient recalls injuring the knee years ago and underwent a course of physical therapy. The provider indicates the physical examination of the left knee is entirely normal with no interior or posterior instability, full range of motion, and intact reflexes. The provider states an x-ray of the knee was not done. There is a recommendation for physical therapy of the left knee. A physical therapy daily note indicates physical therapy was initiated and this is the eighth visit for physical therapy for the left knee. A progress report reveals presentation for follow-up of chronic intermittent left knee discomfort. There is persistent left knee pain despite treatment with physical therapy. The pain increases with activities. The pain comes down with rest. 

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

Yes. The provided documentation indicates the patient was seen for evaluation of chronic left knee pain and a giving way sensation at which time the provider referred the patient to physical therapy. A six-week course of physical therapy was completed. Upon reevaluation  there was persistent left knee pain despite the treatment with physical therapy and the provider ordered an MRI of the left knee. The x-rays were negative. The provided eviCore policy criteria for the knee MRI are met. In addition, the American College of Radiology appropriateness criteria for chronic knee pain support MRI as the next imaging study when there is chronic knee pain and initial radiographs are negative. Based on the provided documentation, the requested health service/treatment of an MRI is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Radiation Therapy

Diagnosis: cancer-small cell lung cancer.
Treatment: intensity modulated radiation therapy (IMRT).
The insurer denied IMRT. 
The health plan's determination is overturned. 

This is the case of a female patient with small cell lung cancer who presented with a single metastatic lesion in brain. She is being evaluated for whole brain radiation using hippocampal sparing intensity modulated radiation therapy (IMRT). This is the subject of this review.

The requested Intensity-Modulated Radiation Therapy (IMRT) as the method of delivering Whole Brain Radiation Therapy (WBRT) is medically necessary for this patient. This is a young patient in good performance status whose primary disease in the lung is controlled. She has single metastatic disease. Hippocampal sparing IMRT treatment is appropriate and medically necessary to avoid long-term memory effects on the brain.
National Comprehensive Cancer Network (NCCN) guidelines recommend this IMRT for this patient's clinical scenario. There are published randomized trials showing improved outcome of this treatment compared to conventional whole brain radiation treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic Cardiomyopathy
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient underwent implantation of a biventricular implantable cardioverter defibrillator for primary prevention of sudden cardiac death and for cardiac resynchronization therapy. His medical history was remarkable for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, congestive heart failure, left bundle branch block and alcohol abuse. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. He remained stable overnight. A chest x-ray showed stable lead position and no evidence of a pneumothorax. Device interrogation showed appropriate lead function. The patient was discharged. At issue is the medical necessity of an inpatient admission.
An inpatient stay was not medically necessary for this patient.
This patient presented for elective biventricular implantable cardioverter defibrillator (ICD) placement. He was hemodynamically stable and the procedure was uncomplicated. While overnight observation after this procedure is still the preferred approach for many implanting physicians, this can generally safely be accomplished at a lower level of care; an inpatient admission is not medically necessary for the vast majority of patients. Same day discharge after ICD implantation (including biventricular device implantation) is an increasingly common practice and has been shown to be feasible and safe in most cases, with no increase in death, readmission or procedural complications when compared to patients who were admitted overnight.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right distal femur chondroblastoma. 
Treatment: Continued Inpatient Rehabilitation Facility stay. 

The insurer denied the Continued Inpatient Rehabilitation Facility stay. 
The denial is overturned. 

The patient is a male with history of Right distal femur chondroblastoma. He
subsequently had tumor resection with Right distal femur with knee hinge
replacement. 

The patient was subsequently admitted to acute inpatient rehabilitation facility (IRF) while partial weight-bearing and anemic. He was running low H/H
(hemoglobin/hematocrit) of 9.8/29.9.

Prior to admission, the patient was independent with ADLs (activities of daily living)
working as a student radiation technologist and living with family in a three-story
house. He was using cane for support. 

The patient's weight-bearing status was noted to be 50% right lower extremity for
six weeks. He was ambulating 35 feet using rolling walker with supervision,
required supervision for upper body dressing/bath, required minimum assistance
with bed mobility, transfers, toilet transfer, sit-to-stand, required moderate-maximum
assistance to negotiate three steps up with right rail, required moderate-maximum
assistance for lower body dressing/bath. He had limited ROM (range of motion) of
Knee from 0-90. The anticipated discharge was to home. 

Yes, the Continued Inpatient Rehabilitation Facility stay was medically necessary. 

The patient met all the criteria for acute rehabilitation care INTERQUAL Criteria for
Acute Rehabilitation in a patient with orthopedic issues. The patient's weight-
bearing status was noted to be 50% right lower extremity for six weeks. He was
ambulating 35 feet using rolling walker with supervision, required supervision for
upper body dressing/bath, required minimum assistance with bed mobility,
transfers, toilet transfer, sit-to-stand, required moderate-maximum assistance to
negotiate three steps up with right rail, required moderate-maximum assistance for
lower body dressing/bath. He had limited ROM (range of motion) of Knee from 0-
90. The anticipated discharge was to home. 

Based on meeting the requirements for continued acute inpatient rehabilitation, it
was medically necessary for patient to continue the acute inpatient rehabilitation, as
he required improvement in ambulation for safety reason and to decrease risk of
falling and also improve lower body dressing/bathing in view of OT (occupational
therapy) and PT (physical therapy) rehabilitation. All of this would not have been
available in a lower level of care. Therefore, continued acute IRF (inpatient
rehabilitation facility) admission was medically necessary. 

Based on the above rationale, the patient with history of surgical tumor excision
right distal chondroblastoma with knee arthroplasty is more than likely to benefit
from an acute rehabilitation that is more than likely to help him towards greater
independence as compared with a lower level of care. 

Therefore, the continued acute IRF (inpatient rehabilitation facility) was medically
necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (class two malocclusion with constricted palate).
Treatment: Comprehensive orthodontic treatment of the adolescent dentition (code D8080) and periodic orthodontic treatment visits (code D8670).
The insurer denied coverage for comprehensive orthodontic treatment of the adolescent dentition (code D8080) and periodic orthodontic treatment visits (code D8670)
The denial is overturned. 

This patient is a female child who was evaluated for orthodontia. The patient has a class two malocclusion with constricted palate. The patient is a thumb sucker which further complicates her condition. The orthodontic exam revealed a 10 millimeter (mm) overjet and 7 mm overbite. There was also significant crowding. This is an appeal for comprehensive orthodontia.

Based on the records provided, the x-rays and photographs, it appears the plan did not act reasonably. It is clear that the Orthodontist noted the patient has a 10 mm overjet which would qualify for coverage. From x-rays the patient has a greater than 9 mm overjet anteriorly. With this noted, this case meets criteria for coverage as this is an auto qualifier on the Handicapping Labio-lingual Deviation (HLD) index.      

Parker noted "The purpose was to study the results of applying the HLD (CalMod) Index to a very large population of patients. The materials were the study models of 1000 cases that had already been measured and approved for treatment. Each model was remeasured and studied. The average age of the patients was 14.138 years of age; 55% were females and 45% were males. Fifty-six percent were approved on the basis of a score of 26 or more, and 44% were approved as one of the exceptions in the index. Fifty-eight percent of the patients were Class I, 35% were Class II, and 7% were Class III. Surprisingly, 26% of all the approvals (19% adjusted for overlap) were for overjets greater than 9 mm. Reverse overjets occurred at the rate of 2% of approvals. Deep impinging overbites with tissue destruction comprised 12% of all approvals and crossbites of individual anterior teeth with tissue destruction 4%. Only 4 cleft palate cases were recorded, as they do not routinely enter the system through the index route. No traumatic deviations were found. The HLD (CalMod) Index has been field tested under a very heavy load. This study demonstrated that it selects a very wide range of malocclusions." 

The medical necessity for comprehensive orthodontic treatment of the adolescent dentition (code D8080) and periodic orthodontic treatment visits (code D8670) is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression. 

Treatment: Concerta ER [extended-release] 18 mg [milligrams] Tablet to Treat Depression.

The insurer denied coverage for Concerta ER 18 mg Tablet to Treat Depression.

The denial is overturned. 

This is a female patient who was in outpatient mental health treatment due to depressive symptoms, anxiety, obsessive compulsive symptoms, and attention problems. She had diagnoses of Major Depressive Disorder and Attention Deficit Hyperactivity Disorder (ADHD). She was taking Prozac and Wellbutrin and also was taking brand name Concerta for over 4 years with reported efficacy for ADHD and depression. 

The insurer denied the request for coverage for brand name Concerta 18 mg [milligrams] per day. They stated that this is considered medically necessary if the patient has a diagnosis of ADHD, narcolepsy, depression and treatment with another medication for depression, fatigue related to cancer, or idiopathic hypersomnolence diagnosed by a sleep clinic, documented intolerance to Vyvanse, dextroamphetamine/amphetamine ER [extended-release], or dexmethylphenidate ER.

In this case, this patient responded to brand name Concerta 18 mg per day and had an improvement in her depressive and ADHD symptoms and no reported medication side effects. The generic medication was not effective and resulted in medication side effects. She responded best to the brand name Concerta.  Also, this is Food and Drug Administration (FDA) approved for ADHD and she had a reported diagnosis of ADHD.  Also it met the insurer's criteria as she had a diagnosis of ADHD, had depression and was taking other antidepressants including Selective serotonin reuptake inhibitors (SSRI), Prozac, and a dopamine norepinephrine reuptake inhibitor in Wellbutrin, and she had adverse effects and lack of efficacy reported when taking other psychostimulants of methylphenidate and dextroamphetamine/amphetamine. This patient responded to Concerta brand name and it is FDA approved for ADHD and also is used for the treatment of major depressive disorder, especially when used in combination with other antidepressants, which was the case with this patient.  Furthermore the fact that she had reported efficacy with depression and ADHD symptoms and had worsened depressive and ADHD symptoms when not taking this including suicidal ideation is further evidence that brand name Concerta was considered medically necessary treatment then.  

Brand name Concerta 18 mg per day is medically necessary. It did not appear that the health care plan acted reasonably or in the best interests of the individual then.

The carrier's denial of coverage for the Pre-Service Request for Concerta ER 18 mg Tablet to Treat Depression is overturned. The medical necessity is substantiated.