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

Diagnosis: functional impairment
Treatment: personal care worker (PCW) services of 24 hours per day, 7 days per week (live-in)
The insurer is denied coverage for personal care worker (PCW) services of 24 hours per day, 7 days per week (live-in).
The denial is overturned. 

This female patient has a history of hypertension, osteoarthritis, hypercholesterolemia, displacement of the intervertebral disc of the lumbosacral region, spinal stenosis of the lumbar region with neurogenic claudication, pneumonia and pressure ulcers in the buttocks area.  

Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with all daily activities. This includes preparation and service with all 3 meals per day and assistance as needed with eating. She needs routine (activity of daily living) ADL assistance including bathing daily, and personal hygiene and dressing morning and evening.  She needs assistance for toileting and incontinence care which occurs at various unscheduled times of the day and night. The patient's mobility is severely impaired, and she needs help for transfers in and out of bed; for ambulation (when she is able); and/or wheelchair mobility. She needs assistance with bed mobility for repositioning for pressure relief, and (when needed) for pain relief. 

There are no nighttime activity records provided for review to help determine the frequency of the patient's nighttime ADL needs. However, it is apparent from the available information that the patient needs assistance for daily activities beyond 8 hours per day and into the evening and night hours. She has episodes of incontinence through the evening/night which she is unable to manage unassisted. Incontinence care and repositioning in bed are medically necessary to help prevent skin injury. She also has h/o chronic pain and limited ability to provide pain relief without caregiver assistance; and so having a caregiver during the day and night is necessary for effective pain management. Eating and drinking at any time of the day or night requires assistance from a caregiver to ensure adequate and safe intake with proper positioning if she is eating and drinking in bed.

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 the personal care worker (PCW) services of 24 hours per day, 7 days per week (live-in) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Benign Prostatic Hyperplasia (BPH)
Treatment: Cystourethroscopy with Urolift
The insurer denied the Cystourethroscopy with Urolift
The denial is overturned. 

The patient is a male with severe lower urinary tract symptoms (American Urologic Association [AUA] symptom score of 20-35) including urinary frequency, hesitancy, incomplete voiding, double voiding, weak stream, nocturia three times (X3) with some relief from Tamsulosin.  The provided office notes have the start date of Tamsulosin. Ultrasound (US) demonstrated a prostate volume of 41 milliliters (mL); cystoscopy demonstrated bilobar prostate enlargement. The patient underwent cystoscopy and Urolift with operative note reporting moderately enlarged prostate with bilobar configuration.

Yes, the proposed cystourethroscopy with Urolift is medically necessary.
The documentation provided supports that the patient has severe lower urinary tract symptoms (American Urologic Association [AUA] 20-35) with symptoms of urinary frequency, hesitancy, incomplete voiding, double voiding, nocturia and weak stream.  He was placed on Flomax and his surgery was performed two months later. The patient has been on medical therapy which did not adequately improve his symptoms. The patient's prostate volume is 41 milliliters by ultrasound.  The patient's cystoscopic evaluation prior to the procedure and at the time of the procedure indicates "bilobar hypertrophy" which means that there is enlargement of both lateral lobes and no middle lobe enlargement.  The proposed cystourethroscopy with Urolift is therefore appropriate and medically necessary for this patient.

Bilobar prostatic enlargement is a term that applies to enlargement of both lateral lobes without enlargement of the middle lobe. This patient was denied coverage due to lack of documentation of no middle lobar enlargement; however, the use of the term bilobar enlargement of the prostate was used prior to cystoscopy and at the time of the cystoscopy.  The appeal letter notes the operative findings as bilobar enlargement.  The definition of bilobar adenoma in the literature includes "prominent lateral lobes with kissing appearance without a prominent median lobe".  Therefore, the health plan did not act reasonably as this procedure is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cataract.
Treatment: Laser Procedure: YAG Capsulotomy (left eye).
The insurer denied a Laser Procedure: YAG Capsulotomy (left eye). 
The health plan's determination is overturned. 

The patient is a female who had cataract surgery and has developed a secondary cataract or posterior capsular opacification of her left eye. The patient was complaining of blurred vision with reduction of vision to 20/150 in her left eye. The patient underwent a YAG (Yttrium aluminium-garnet) capsulotomy of her left eye opacification with improvement of vision to 20/20. Under review is the medical necessity of Laser Procedure: YAG Capsulotomy (left eye).

Laser Procedure: YAG Capsulotomy (left eye) is medically necessary for this patient.
YAG capsulotomy is a common procedure performed after cataract surgery. It was needed and medically necessary in this patient to improve vision. Without treatment the vision would progressively become worse.
It was best for the patient to have a YAG capsulotomy to improve her vision. Posterior capsular opacification is a common development after cataract surgery and it occurs in 20-50% of cases. The treatment is a YAG capsulotomy to open up the posterior capsule and to improve vision.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hematuria and abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient is a male without significant past medical history who was admitted with hematuria and abdominal pain.  Computed tomography of the abdomen/pelvis demonstrated mild to moderate bilateral hydroureteronephrosis and bilateral perinephric stranding.  The patient was afebrile with a blood pressure 173/95 pulse 94.  Labs were notable for white blood cell count 20,800, glucose 188, potassium 5.1, bicarbonate 19, BUN (blood urea nitrogen) 146, and creatinine 7.1.  The urinalysis was positive for leukocyte esterase, bacteria, and white blood cells.  Intravenous fluids intravenous antibiotics were provided.  A Foley catheter was placed.  Serial glucose levels were followed and sliding scale insulin was administered.  The creatinine on follow-up was 3.0, 2.3, 1.7, and 2.6.  Amlodipine and glipizide were initiated.  The urine culture was negative.  The patient was discharged on tamsulosin and finasteride.

The member had severe acute kidney injury on admission with a BUN 146 and creatinine 7.1, with no preceding history of chronic kidney disease.  This was accompanied by hyperkalemia and metabolic acidosis.  Renal function improved initially with the creatinine dropped to 1.7 mg/dL but subsequently worsened with a rise in creatinine to 2.6.  The member additionally was newly diagnosed with diabetes, indicating he was in immunocompromised state.  He had bilateral pyelonephritis noted on computed tomography of the abdomen/pelvis with evidence of urinary obstruction on admission, and with a significant degree of leukocytosis.  Intravenous antibiotics and intravenous fluids were required.  In summary, inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic systolic heart failure with reducedejection fraction (40-45%), hypertension (HTN), and atrial fibrillation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of ischemic systolic heart failure with reduced ejection fraction (40-45%), hypertension (HTN), and atrial fibrillation.  He presented to the hospital for an elective catheter ablation of atrial fibrillation and atrial flutter.  He underwent uncomplicated pulmonary vein isolation and cavotricuspid isthmus atrial flutter ablation and was discharged home the following day.

No, inpatient hospital admission following uncomplicated ablation of atrial fibrillation and atrial flutter is not medically necessary.
This patient presented to the hospital for an elective electrophysiological study and ablation. According to hospital records, the ablation was successfully performed without complication.  Observation following ablation was unremarkable and no post operative issues were noted.  The patient was discharged home the following day.  

In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after electrophysiological study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. (Reference 1)  Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth fracture.
Treatment: D2954 tooth #14; D2750 tooth #14.
The insurer denied the D2954 tooth #14; D2750 tooth #14.
The denial is overturned. 

The patient is a female requesting dental benefits on tooth #14 (D2954 - prefabricated post and core; D2750 - crown).  The patient presented with bleeding and swollen gums.   The patient presented with fracture to tooth #14; she stated she was experiencing pain upon chewing/biting down. Tooth #14 already had a large amalgam filling covering approximately 85 percent of the occlusal surface.  X-rays, photos, and clinical consultation were performed.  

The Health plan denied the crown due to no decay or injury present on tooth #14.  The provider appealed the claim based on the condition of tooth #14.

Yes, the proposed treatment of a prefabricated post and core and crown on tooth #14 was medically necessary.
Due to the very large existing filling and the area of fracture on the lingual aspect of tooth #14, a prefabricated post and core and crown is the standard of care to prevent the tooth from further fracture and restore function and comfort to this patient.

No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient as the prefabricated post and core and crown on tooth #14 was medically necessary.
Given the condition of tooth #14 and the patients symptoms, if left untreated, this would only lead to further fracture and may eventually lead to tooth loss. The tooth may further fracture in a manner such that it becomes non-restorable and would need to be extracted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: VLCAD (very long chain acyl-Coenzyme A dehydrogenase) deficiency
Treatment: Dojolvi SGM
The insurer denied the Dojolvi SGM
The denial is upheld. 

The patient is a girl with a diagnosis of very long chain acyl-Coenzyme A dehydrogenase (VLCAD) deficiency. She has frequent episodes of vomiting and headache and was recently diagnosed with cyclic vomiting syndrome. She did have episodes of mild hypoglycemia when younger. She is now clinically stable with respect to her VLCAD (very long chain acyl-Coenzyme A dehydrogenase) without rhabdomyolysis or myoglobinuria, although she does have muscle pains, and is treated with medium chain triglyceride oil and betaquik. However, she is variably or not compliant with carnitine or MCT (mediumchain triglyceride) Oil supplements. Plasma carnitine levels are normal. Other medical problems include abdominal pain, adjustment disorder with anxious mood, ADHD (attention deficit hyperactivity disorder), chromosomal abnormalities of chromosome 7 and 16, excessive sweating, fatigue, constipation, gait difficulty, hyperhidrosis, learning disability, scoliosis, self-injurious behavior, and urinary retention. She does not have cardiomyopathy. Molecular genetic testing demonstrated one pathogenic variant and one variant of uncertain significance in the VLCAD (very long chain acyl-Coenzyme A dehydrogenase) gene.

The patient's provider has requested Dojolvi, an alternative to medium chain triglycerides, as a dietary supplement in her to hopefully improve her compliance with dietary management of her VLCAD (very long chain acyl-Coenzyme A dehydrogenase), and her general clinical state and prevent episodes of hypoglycemia and/or rhabdomyolysis.

No, the requested Dojolvi is not medically necessary.
While Dojolvi is the only FDA (United States Food and Drug Administration)-approved dietary supplement for VLCAD (very long chain acyl-Coenzyme A dehydrogenase), it is not necessary for all patients with this disorder of long chain fatty acid oxidation. This young woman does not have active current rhabdomyolysis, muscle disease directly caused by deficiency of this enzyme of long chain fatty acid oxidation, hypoglycemia, or cardiomyopathy. Therefore, given the mild to moderate clinical presentation of her disease, replacement of medium chain triglyceride supplements with Doljovi is not medically necessary, clinically appropriate, and is not supported by the current treatment guidelines for VLCAD (very long chain acyl-Coenzyme A dehydrogenase) patients with mild to moderate disease.

Given that this individual has only mild to moderate VLCAD (very long chain acyl-Coenzyme A dehydrogenase) deficiency that is largely asymptomatic and well-controlled on MCT (mediumchain triglyceride) supplements, Dojolvi supplementation is not medically necessary or clinically appropriate in her specific clinical context. As such, health plan acted reasonably with sound medical judgment and in the best interest of the patient in this specific clinical context and scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot Infection.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

The patient has a past medical history significant for methamphetamine use, and presented to the emergency department with complaints of left foot swelling and pain. The patient had injured the same foot two weeks earlier.  Vitals on presentation included: Temperature 98 Fahrenheit, Blood Pressure 139/71, Pulse 86, Respiratory Rate 18, oxygen (O2) saturation 99% [percent] on Room Air. Laboratory results included the following: white blood cell count (WBC)11.35, hemoglobin (HGB)-12.2, hematocrit (HCT)-37.3, creatinine-0.8, and glucose-72.

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for a left foot infection. X-ray of left foot was negative for fracture or dislocation. Computed tomography (CT) scan showed soft tissues edema with discrete abscess or collection. Infectious Diseases and Podiatry consulted. Cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Patient underwent incision and drainage procedure. The patient remained afebrile and hemodynamically stable. He was discharged on oral antibiotics and continued outpatient wound care.         

According to documentation, patient presented the emergency department with a left foot infection. He was initially admitted to the observation unit and started on multiple intravenous antibiotics. Although patient was afebrile and hemodynamically stable, WBC was slightly elevated. Clinically, he complained of 10 out of 10 pain. An incision and drainage procedure was performed and they were awaiting results of wound culture to adjust antibiotic therapy. Cultures grew MRSA. Based on above findings in a high-risk patient with history of methamphetamine use and recent injury to the same foot, hospital admission was medically necessary for surgical intervention and intravenous antibiotics.     

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 reversed. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines. 
Treatment Ubrelvy (ubrogepant). 

The insurer denied coverage for Ubrelvy (ubrogepant). 

The denial is upheld. 

The patient has rare migraines with brainstem aura.  Triptans are relatively contraindicated given risk of devastating stroke.  The Neurologist prescribed Ulbrelvy, a non-triptan acute migraine treatment.  This was denied as non-formulary.  The Neurologist is appealing based on the contraindication to triptans.  However, there is a non-triptan agent on formulary: Nurtec, which is appropriate for this patient. 

The patient has not tried and failed the formulary option. The formulary drug is not expected to have an adverse reaction and is not contraindicated. Nurtec (rimegepant) is very similar to Ulbrelvy (ubrogepant). "Ubrogepant received US [united states] Food and Drug Administration (FDA) approval for the treatment of acute migraine in adults, and rimegepant [Nurtec] received similar FDA approval...They are both CGRP [calcitonin gene-related peptide] antagonists. 

There is no reason to think Ulbrevy would be more effective than Nurtec. They have the same mechanism of action. 

The insurer's denial of coverage for Formulary Exception request for Ubrelvy (ubrogepant) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pes planus 
Treatment: Orthotics (Shoe Inserts)
The insurer denied Orthotics (Shoe Inserts). 
The health plan's determination is upheld.

The patient is a male who was seen by his provider for evaluation and need of new orthotics. Physical Exam reveals pain on palpation of the medial, central band of the plantar fascia. The patient was diagnosed with plantar fasciitis. The patient was recommended and received custom molded orthotics. The patient was seen again and was stating he felt like he needed more support. The patient was advised to start non-steroidal anti-inflammatory drugs (NSAIDs), wear proper shoe gear including a Spira shoe. The patient was recommended stretching and requested and received orthotics. The patient was later seen and again was stating that he felt like he needed more support in his feet. There was no documentation subjectively or objectively of pain to his heel. The patient was diagnosed with pes planus and calcaneovalgus deformity. The patient was recommended to keep taking NSAIDs, wear proper shoe gear, stretching and custom molded orthotics.
The issue is the medical necessity of the custom molded orthotics.

The requested Custom Shoe inserts are not considered medically necessary. The patient was diagnosed with pes planus deformity. Medical research does not support custom molded orthotics for pes planus deformity. The patient does not have any subjective or objective documentation of pain. Custom molded orthotics are not considered medically necessary in this patient at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria.
Treatment sexual reassignment surgery (procedure code 19303).
The insurer denied coverage for sexual reassignment surgery (procedure code 19303).
The denial is overturned.

This transgender male (female-to-male [FtM]) patient has a medical history of gender dysphoria, generalized anxiety disorder, major depressive disorder, and attention deficit hyperactivity disorder (ADHD). The request is for coverage of sexual reassignment surgery (procedure code 19303), which the insurer has denied. 

The health plan did not act reasonably in the best interest of the patient. The procedure 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" 7th Edition guidelines:

Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in 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 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 guidelines are as follows: "Chest surgery in FtM 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 one year ago. Mental health concerns are managed by his therapist.  His psychologist has recommended the mastectomies. The standard of care for adolescent top surgery is met.

The insurer's denial of coverage for sexual reassignment surgery (procedure code 19303), to be provided is reversed. Medical necessity is substantiated.