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

Diagnosis: s/p (status post) Cerebral Artery Aneurysm.
Treatment: Continued Nursing Home Services .
The insurer denied the Continued Nursing Home Services.
The denial is overturned.

The patient is a male with history of general debility, with right dense hemiplegia and right eye blindness, status post Subarachnoid Hemorrhage secondary to Left Anterior Cerebral Artery Aneurysm status post coil embolization.

Prior to admission, the patient was undomiciled.

The patient required set-up to very minimal assistance for most ADLs (activities of daily living) while able to ambulate 175 feet using quad cane and Right KAFO (knee-ankle-foot orthosis). He has problem with discharge, as the only option is to a homeless shelter while his continued stay was custodial. The request is for continued respite custodial care while awaiting safe discharge under the TBI (traumatic brain injury) waiver program.

Yes, the Continued Nursing Home Services are medically necessary.
The patient's current status is dense Right hemiplegia and Right eye blindness with the only discharge option being to a homeless shelter. This will not be adequate for him. Therefore, respite custodial care is necessary. Therefore, the Continued Nursing Home Services are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient required set-up to very minimal assistance for most ADLs (activities of daily living) while able to ambulate 175 feet using quad cane and Right KAFO (knee-ankle-foot orthosis). He has problem with discharge, as the only option is to a homeless shelter, while his continued stay was custodial. The request is for continued respite custodial care while awaiting safe discharge under the TBI (traumatic brain injury) waiver program.

The patient cannot be discharged due to his impairments, as his only option is to a homeless shelter. Therefore, the best option is to continue the current respite custodial care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: symptomatic excess bilateral breast skin

Treatment: breast lift surgery

The insurer is denied coverage for breast lift surgery

The denial is upheld. 

This female patient has a history of diabetes, obstructive sleep apnea (OSA), and weight loss following bariatric surgery.

According to Chapter 58, Grabb and Smiths Plastic Surgery, "Mastopexy is a procedure designed to elevate breast tissue and the nipple-areola complex to correct breast ptosis. Mastopexy procedures are derived from breast-reduction procedures except that only skin is removed with little or no parenchymal resection. Breast reduction surgery is often performed to relieve neck, back, shoulder, and arm pain. The patient receives significant medical and quality-of-life benefits. Although the appearance of the breast is a factor, the medical benefits are often the primary concern of the patient. Mastopexy is almost always a cosmetic procedure. Consequently, the trade-offs (i.e., scars) are less well tolerated by the mastopexy patient than by the breast-reduction patient."  

There are no peer-reviewed studies that show that mastopexy is an effective treatment for musculoskeletal pain or is a superior treatment to dermatology management for rashes. In addition, the records do not include any PCP or dermatology notes that document medical treatment of rashes.  Mastopexy will not improve health outcomes and is not medically necessary. It is being performed for appearance and patient convenience.

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

The carrier's denial of coverage for breast lift surgery is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis

Treatment: acute inpatient level of care

The insurer is denied coverage for acute inpatient level of care

The denial is overturned. 

This male patient has a history of hyperlipidemia and hypertension

The patient was admitted for hand infection following dog bites. He was started empirically on antibiotics (vancomycin and Zosyn). Orthopedics consulted and performed an incision and drainage of the right ring finger. Preliminary culture results were positive for gram positive cocci. Final cultures grew Staphylococcus aureus and Stenotrophomonas maltophilia. The patient left hospital against medical advice (AMA).

Malodorous drainage was noted from right ring finger. Laboratory results were notable for abnormal liver function tests.  X-ray of the hand showed partial amputation of the distal tuft of the fourth digit with adjacent soft tissue injury. Based on above findings, hospital admission was medically necessary for administration of intravenous antibiotics, surgical intervention, and alcohol withdrawal precaution.    

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

The carrier's denial of coverage for acute inpatient level of care is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity weakness. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This female patient has a history of right sided breast cancer. 

The patient presented to the emergency department (ED) with a 2-3 day history of lower extremity weakness. Neurology was consulted. The patient was treated with intravenous (IV) fluids and felt much better the following day and could ambulate without assistance. The patient was then discharged to home with outpatient follow up arranged. Care provided, including diagnostic testing, specialty consultation and medical management which could have been performed in the ED and at an observation level of care. Therefore, the inpatient admission was not medically necessary. 

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

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Orthodontic Treatment
The insurer denied the Orthodontic Treatment.
The determination is overturned.

The patient has impacted teeth 6 and 11, and an anterior crossbite of teeth 8 and 9. She presented with a Class II malocclusion and severe crowding. She is treatment planned for orthodontics to address the crowding and to create space to bring the impacted teeth into the arch. The treatment was denied due to a lack of medical necessity and is under review.

Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. (2) The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. (2) If left untreated, the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. Even if the canines were simply extracted the patient would have a medical need for orthodontic treatment due to her anterior crossbite. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (3,4,5).
For these reasons, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endodontically treated tooth
Treatment: White Glass with Metal Crown, Tooth #19
The insurer denied the White Glass with Metal Crown, Tooth #19
The denial is overturned.

The patient is a male. The request is for a white glass with metal crown on tooth #19. X-rays show that the tooth is endodontically treated (root canal) and an existing restoration is present.

The Health plan is denying the claim because the restoration is considered inadequate because it does not come all the way to the top.  An appeal is being made to place a protective crown on this tooth.

Yes, the proposed treatment of a white glass with metal crown is medically necessary for tooth #19.
The patient presents with x-rays confirming that tooth #19 was endodontically treated (root canal).  The standard of care for an endodontically treated tooth is to have a full coverage crown placed to restore form and function of the tooth.  When a tooth has been endodontically treated the nerves and the blood vessels are removed and the tooth becomes brittle and is subject to fracture.

The health plan's argument that the existing filling is inadequate because it does not come to the top of the tooth is irrelevant for the need to restore the tooth with a crown.

The crown preparation process will have to reduce all surfaces of the existing tooth and filling material; the condition of that filling should be addressed as it is contoured and adjusted to accommodate the crown.  The fact that the filling is inadequate is even more reason that the tooth should be crowned based on the existing and current condition of the tooth #19 as presented on the x-ray.

The standard of care is for all endodontically treated teeth (root canal) to receive a full coverage crown for protection from fracture and to restore function. 

In not approving a crown for this tooth, the patient runs a risk of fracturing this tooth and possibly eventual tooth loss.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria. 
Treatment: Surgical.
The insurer denied top surgery. 
The health plan's determination is overturned.

The patient is a female to male transgender. He complains of acute dysphoria due to the appearance of his chest. He has been on testosterone. He has been living as a male for several years. He has legally changed his name. Top surgery is planned and is under review for medical necessity.

The requested service of top surgery is medically necessary for this patient. Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:
Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in female to male (FtM) 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 standard of care [SOC] 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 guidelines are as follows: "Chest surgery in F to M 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. Three mental health professionals have recommended top surgery. He has lived as a male for several years. Mental health concerns are managed by his therapist. The standard of care for adolescent top surgery is met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain.
Treatment: pain management services- implant spine infusion pump.
The insurer denied pain management services- implant spine infusion pump.
The determination is overturned.

The patient has a history of a previous intrathecal morphine pump that was implanted previously with good pain control. She has been having localized pain at the pump site, due to the pump reservoir being mobile in the pocket to the point of flipping back and forth. There are no signs of infection. The provider recommended revision of the pain pump reservoir, specifically to secure it in the pocket. The actual reservoir per se does not need to be replaced. At issue is the medical necessity of pain management services- implant spine infusion pump.

The patient has hypermobility of her pump with pain, and also carries a risk of future malfunction. The procedure is medically necessary.
The request for revision of the morphine pump reservoir is medically necessary. The pump reservoir is relatively large and can cause pain or discomfort. The pump is very mobile, to the point of flipping back and forth. This is not only a pain issue, but there is risk of malfunction of the device with this hypermobility.
There is evidence in the literature of device complications, including hypermobility of the reservoir. Noon et al cite "Intrathecal (IT) pumps are sophisticated, implantable, mechanical devices designed to safely deliver pain medications to patients with chronic pain and spasticity over long periods of time. An IT drug delivery system consists of an intrathecal catheter and a "pump"-a device containing a drug reservoir, pumping mechanism, and often a battery for driving drug delivery. Each of these components can fail and lead to serious and potentially lethal complications due to either human error and/or device failure. Device stalls, pump flips, battery failures, and catheter fractures can present as acute underdosing, resulting in medication withdrawal symptoms. Over-infusion of medication due to malfunctioning of the pump delivery system can also occur, resulting in an acute medication overdose. Both under- and over-infusion states are dangerous complications and potentially lethal. Pucks-Faes cite in a series "Pump-related problems were caused by hypermobility (1/32) and by pump site infections (3/32 in three patients". Lastly, Ahmad et al cite "Besides adverse effects, there are not many serious complications reported for intrathecal drug delivery system implantation itself. Some of the common complications are infection of the meninges, granuloma formation at the tip of the subarachnoid catheter, bleeding or hematoma at the site of the surgery, and malfunctioning of the device. Theses device malfunctions are reversible and the rest of the complications are treatable".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiomyopathy. 
Treatment: Vyndamax. 

The insurer denied Vyndamax. The health plan's determination is overturned. 

This case involves a male with a history of atrial fibrillation, obstructive sleep apnea (OSA), and hyperlipidemia, who has developed progressive shortness of breath and fatigue. Records indicate that the patient has been diagnosed with heart failure with preserved ejection fraction due to Transthyretin Mediated Amyloidosis with Cardiomyopathy (ATTR-CM). Stress test has been negative for ischemia. Echocardiogram imaging has shown normal ejection fraction (EF) with left ventricular hypertrophy (LVH). PYP (technetium phyrophosphate) scan was highly positive for TTR cardiac amyloid with visual score of 3 and H/L (heterophils and lymphocytes) ratio 1.7. Serum and urine testing has excluded a monoclonal protein. Pro brain (or B-type) natriuretic peptide (BNP) is high (1175). The patient's Cardiologist has appropriately recommended treatment with Vyndamax 61 milligrams (mg) capsule for the treatment of TTR cardiac amyloidosis. 

The patient's history and cardiac testing is consistent symptomatic heart failure with preserved ejection fraction due to ATTR cardiac amyloidosis. Given that the diagnosis of TTR cardiac amyloidosis has been made in this case, treatment with Vyndamax, as recommended by the patient's cardiologist, is medically appropriate and necessary to reduce the risk of cardiovascular-related hospitalizations and mortality as well as improve this patient's quality of life. The patient's evaluation and treatment recommendation to start Vyndamax are consistent with current standard of care for TTR cardiac amyloidosis as supported by peer-reviewed medical literature on the evaluation and treatment of ATTR cardiac amyloidosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Transplant
Treatment: Prevymis 480 mg
The insurer denied Prevymis 480 mg.
The determination is overturned.

The patient has a history of hypertension (HTN) and end-stage heart failure who underwent heart transplantation. Post-heart transplant, the patient has developed chronic renal disease and significant pancytopenia attributed to the anti-cytomegalovirus (CMV) prophylaxis medication, Valcyte. His immunosuppression has been adjusted accordingly to minimize the ongoing risk of pancytopenia. To reduce the risk that the patient will develop morbidity and mortality from future CMV disease, the patient's heart transplant physician has requested authorization for Prevymis 480 milligrams (mg) for the prevention of CMV disease in this high-risk heart transplant recipient (D positive (+)/R negative (-)). Because Prevymis is not currently Food and Drug Administration (FDA) approved for solid organ transplantation, the patient's health plan has denied coverage for Prevymis due to a lack of medical necessity. The Prevymis 480 mg is under review.

The recommendation of Prevymis 480 mg is medically appropriate and necessary for CMV prophylaxis, as a second line agent, in this case due to patient's intolerance to Valcyte and need for continued treatment to protect against developing CMV disease.
This patient has undergone heart transplantation and is at significant risk for both heart transplant rejection and infection that can result in both morbidity and mortality. For this reason, the patient requires post-operative anti-viral prophylaxis against CMV as recommended according to The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients (1). This patient has been intolerant to Valcyte prescribed for the prevention of CMV infection due to severe cytopenias. In order to protect the patient against CMV disease, the patient's heart transplant physician has recommended treatment with Prevymis in place of Valcyte given its efficacy and improved tolerability and lower risk of causing cytopenias (2). While Prevymis is not currently FDA approved for CMV prophylaxis in heart transplant recipients, published medical literature demonstrates effectiveness in prevention of CMV disease and a lower risk of cytopenias (2, 3). For these reasons, Prevymis is medically appropriate and necessary for postoperative CMV prophylaxis in this case. CMV prophylaxis is extremely important for this patient at risk of developing CMV disease which can have major health implications. Given the patient's previously demonstrated intolerance to Valcyte, Prevymis is the next best option for this patient for appropriate CMV prophylaxis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient Hospital
The insurer denied the inpatient stay.
The denial is upheld.

The patient is a female with a history of right hip pain and known osteoarthritis of the right hip. She failed conservative treatment for this condition and elected to undergo right total hip replacement surgery. The surgery was successful with no documented complications. She recovered well after the operation but had one episode of dizziness and hypotension after getting up from her bed. This resolved with an intravenous (IV) fluid bolus. Her vital signs and lab values remained stable throughout the remainder of her hospital admission. She was deemed stable for discharge home. The patient's health plan denied the inpatient hospital admission as not medically necessary. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested health service of an inpatient hospital stay was not medically necessary for this patient. The provided medical records document that the patient underwent an elective right total hip replacement surgery. The surgery was successful with no documented complications. The progress notes did not document any post-operative bleeding complications, nor were there any signs of post-operative infection that would justify the medical necessity of the inpatient stay. The patient had one episode of hypotension when getting up to use the commode, but this resolved with IV fluid administration and her vital signs were normal after this intervention. Thus, the medical necessity of the inpatient hospital stay is not established based upon the documentation in the provided medical records.

The current, peer-reviewed literature has recently documented the safety and efficacy of short stay and outpatient total joint replacement surgery. A recent article published by Grosso and colleagues in the Journal of Arthroplasty concluded that "Over the last decade, there has been a decrease in length of stay and an improved short-term complication profile for total hip arthroplasty. With continually increasing rates of utilization of total hip arthroplasty (THA) along broader patient demographics, these changes are important to help mitigate the costs of higher volume." Based upon this peer-reviewed literature and the documentation in the patient's medical records, the inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has no documented history.

This patient had a missed abortion necessitating a D&C. D&C are ambulatory procedures. D&Cs are done in offices and surgicenters. D&C can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Following a D&C, a patient is usually observed in the recovery room like all patients undergoing an ambulatory procedure and once the provider ascertains that the patient is stable then the patient is sent home. Admission to an acute level of care is not customary or medically necessary. There was no reason submitted why the patient was admitted. 

In addition, blood transfusions do not require admission either as they are done routinely in outpatient settings (oncology clinics, infusion centers even at home). Thus, the need for transfusion is not a reason for admission.

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

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Prior root canal treatment.
Treatment: D2740 Crown Porcelain Ceramic Tooth #7, #8 and #9, Pre-service.
The insurer denied the D2740 Crown Porcelain Ceramic Tooth #7, #8 and #9, Pre-service.
The denial is partially overturned.

The patient is a male requesting crowns on teeth #7, #8, and #9. Teeth #7 and #9 have existing crowns. Tooth #8 has had root canal treatment and is heavily restored with fillings.

Yes, in part; D2740 Crown Porcelain Ceramic on tooth #8 is medically necessary.  However, D2740 Crown Porcelain Ceramic for teeth #7 and #9 is not medically necessary.
Tooth #8 has had a root canal treatment performed on it. It also has three composite fillings in it. These prior procedures will weaken this tooth and a crown is needed to strengthen it. The crown is medically necessary for tooth #8.

Teeth #7 and #9 already have crowns on them and they do not have any evidence of new decay. Therefore, they do not need new crowns.

Yes, in part; the health plan did act reasonably, with sound medical judgment and in the best interest of the patient in denying D2740 Crown Porcelain Ceramic for teeth #7 and #9 as it is not medically.  However, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in denying D2740 Crown Porcelain Ceramic for tooth #8 as it is medically necessary.