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

Diagnosis: Tooth decay. 
Treatment: Root Canal, Post, Core and Crown for Teeth Numbers 8, 9, and 10. 

The insurer denied Root Canal, Post, Core and Crown for Teeth Numbers 8, 9, and 10. The health plan's determination is overturned. 

The patient is  female who presents for evaluation and treatment of teeth # (number) 8, 9, and 10. In question is the medical necessity of Dental Services: Root Canal, Post, Core and Crown for Teeth Numbers 8, 9, and 10. 

Dental Services: Root Canal, Post, Core and Crown for Teeth Numbers 8, 9, and 10 is medically necessary for this patient. As the teeth in question have extensive decay, have involvement of the pulp, and as a direct restoration is not possible, all the therapy listed is required into order to maintain the teeth and to maintain their function. Hence, the entire treatment of Root Canal, Post, Core and Crown for Teeth Numbers 8, 9, and 10 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Buccal decay
Treatment: Replacement for Teeth and/or Quads #18 
The insurer denied the Replacement for Teeth and/or Quads #18 
The denial is upheld

The patient is a female. Tooth #18 was stated to have recurrent buccal decay under an existing crown. Poor quality x-ray presented does not indicate this at all. Prior denial was for lack of proper documentation.

No, the Replacement for Teeth and/or Quads #18 is not medically necessary.
Of the five x-rays provided, four of them are absolutely unreadable, and the fifth x-ray is of extremely poor, undiagnostic quality. There is no way the x-rays can be used to corroborate the written description the provider depicts for this tooth. A photo of the decay is warranted to understand what is needed.

The one bitewing x-ray (poor quality), does not show any decay present to indicate the need for a new crown.

Therefore, given the above, the requested health service is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who presented for cardiac catheterization. The patient had history of coronary artery disease (CAD). The patient was scheduled for left anterior descending (LAD) intervention. The patient presented for intervention on LAD because there was viability study confirming viability of anterior wall. The patient reported that when he came home from the first procedure, he had chest pain at rest, but then it resolved, and he had shortness of breath when getting up from a sitting position. 

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient suffered non ST-Elevation Myocardial Infarction (STEMI) when was admitted previously to this episode of service. The patient underwent coronary intervention and was discharged home. He presented for elective procedure, coronary intervention, which was scheduled. His condition upon presentation was stable, the procedure went as planned, without any complications. His post procedural period was unremarkable, and he was stable without any complications. The patient was observed overnight according to routine protocol. 
The patient's condition and level of care did not meet inpatient admission criteria. The service should have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholestasis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for an inpatient hospital admission. 

The denial is upheld. 

The patient presented with abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal ultrasound revealed a gallstone and a thickened gallbladder wall. The abdominal CAT (Computed axial tomography) scan did not find gallbladder wall thickening. The patient underwent a laparoscopic cholecystectomy. He tolerated the procedure well and no complications were reported. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (MCG (Milliman Care Guidelines) - M-555) include having evidence of acute cholecystitis with abdominal pain and systemic signs of inflammation. This patient had upper abdominal pain but did not have fever and the WBC (White Blood Cell) count was in the labs normal range. He did not have systemic signs of infection. 

This patient had cholestasis and required a laparoscopic cholecystectomy. The abdominal ultrasound was consistent with acute cholecystitis, but the patient did not have fever or leukocytosis. The procedure could have been performed as ambulatory surgery. The health care plan acted reasonably and with sound medical judgment. An inpatient hospital admission was not medically necessary. The denial is upheld. 

The insurer's denial of coverage for an inpatient hospital admission should be upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever and Belly Pain (postpartum endometritis). 
Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission. 
The denial is overturned. 

The patient is a female. She presented three days status post intrauterine fetal demise. She was sent from a medical office for fevers and chills. 

On her exam the patient was afebrile and had normal vital signs, but had significant uterine fundal tenderness without rebound signs. She was admitted to the hospital and given triple intravenous antibiotic treatment with ampicillin, clindamycin, and gentamicin. She remained afebrile and was discharged home on hospital day number 2. 

The health plan denied coverage of the hospitalization based on absence of abscesses or hemodynamic instability and cited InterQual Acute Adult: GI/GYN. The facility contends that the hospitalization was medically necessary due to clinical and guideline standpoints and cites MCG (Milliman Care Guidelines) 25th edition Obstetric and Gynecologic Disease GRG: Clinical Indications for Admission to Inpatient Care, obstetric care requiring hospitalization, endometritis (except mild postpartum endometritis). 

Yes, the inpatient hospital admission was medically necessary. 

Standard treatment for postpartum endometritis requires intravenous administration of a minimum of clindamycin and gentamycin.  Although it is possible to treat very mild cases of endometritis with oral antibiotics, this is generally not recommended, and there is no standard definition of "mild endometritis." Untreated or inadequately treated endometritis can lead to development of severe sepsis, pelvic abscesses, and death. Therefore, given these concerns, standard textbooks of high risk obstetrics (Creasy and Resnick) recommend intravenous antibiotics and requisite hospitalization for treatment of postpartum endometritis. Therefore, the hospitalization was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient, in that it declined payment for inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis (AD). 
Treatment: Dupixent. 

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

The patient is a male with atopic dermatitis (AD). Body surface area affected is 40%. He has tried and could not tolerate methotrexate due to fatigue, dizziness, and vomiting after the first dose. He has tried and failed triamcinolone, clobetasol, and hydrocortisone. He has also failed tacrolimus ointment. The medication under review is Dupixent. 

Dupixent is medically necessary for this patient. The patient has already tried and failed all the conventional therapies. He has tried and could not tolerate methotrexate due to fatigue, dizziness, and vomiting after the first dose. He has tried and failed triamcinolone, clobetasol, and hydrocortisone. He has also failed tacrolimus ointment. 
The use of Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is approved by the Food and Drug Administration (FDA) for the management of atopic dermatitis. In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3). According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies" (1).
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental Disorder. 
Treatment: Nerve treatment tooth #11 and tooth #2, White glass with metal crown tooth #2. 

The insurer denied Nerve treatment tooth #11 and tooth #2, White glass with metal crown tooth #2. 

The determination is overturned in part. 

The patient presented for evaluation and treatment of teeth number (#) 11 and 2. Provided for review are previous letters of appeal and denial, full mouth radiographic images, explanation of benefits, and health plan language. At issue is the medical necessity of the planned treatment of root canal for tooth #11 and 2, as well as porcelain fused to metal crown for tooth #2. 

The requested services/treatment are medically necessary in part. 

For tooth #2, no, the requested health service/treatment of Nerve treatment tooth #2 and white glass with metal crown tooth #2 is not medically necessary for this patient. In regards to tooth #2 with the requested treatment of root canal therapy and porcelain fused to metal crown, the health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. Tooth #2 does not have enough remaining tooth structure to support a crown nor any other restoration and has a hopeless prognosis. 

For tooth #11, the requested health service/treatment of Nerve treatment tooth #11 is medically necessary for this patient. This is a cuspid tooth. Tooth #11 has pulpal exposure and thus irreversible pulpitis. Tooth #11 also has enough remaining tooth structure to allow for restoration. In any situation where the patient has the diagnosis of irreversible pulpits, as long as the tooth is restorable, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of abscess, with an array of sequential systemic sequela. Hence, based on the diagnosis of irreversible pulpits alone, the therapy of root canal therapy is indicated. 

The health plan's determination is overturned in part for allowance of #11 root canal therapy (it is not a molar it is a cuspid) and upheld for tooth #2 root canal (3330) and porcelain fused to metal crown (2751).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Proton Beam Radiation Therapy. 
 
The insurer denied proton beam radiation therapy. 
The health plan's determination is upheld. 

This is the case of a male patient who presented with rising prostate-specific antigen (PSA). A biopsy established a diagnosis of intermediate risk prostate cancer. He is being evaluated for proton beam radiation therapy. 

Proton beam radiation therapy is not medically necessary for this patient. 

Proton beam therapy is a type of particulate radiation therapy that differs from conventional electromagnetic and/or photon radiation therapy. The use of protons is produced by an accelerator (cyclotron, synchrotron, synchrocyclotron, or linear). This type of radiation is proposed to allow for minimal scattering as particulate beams pass through tissue, disposing ionizing energy at precise depths (i.e. [that is], the Bragg peak) to minimize tissue damage in the surrounding area. 

The use of proton beam radiation therapy as definitive treatment for prostate cancer has medical literature with relatively short follow up with proton beam therapy as monotherapy for prostate malignancies. These studies show equivalent control rates to other types of radiation therapy for the shorter follow up periods. There are also retrospective studies with large numbers of patients that have shown worse gastrointestinal (GI) side effects as compared to photon beam radiation therapy with intensity modulated radiation therapy (IMRT). There are a lack of randomized studies regarding proton beam radiation therapy alone as treatment for prostate cancer that show equivalent outcome or any improvement over other forms of radiation therapy such as photon IMRT. Until the current randomized trials ongoing are published in peer reviewed medical literature, this treatment for prostate cancer is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Constipation. 
Treatment: Trulance. 

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

The patient is a female with slow-transit constipation. She has failed lactulose, Miralax, Magnesium Citrate, Senna, Colace, Dulcolax, Linzess. She has been on Trulance. Coverage is being requested for Trulance for the treatment of constipation. The request was not approved as the formulary alternative lubiprostone (generic Amitiza) has not been attempted. 

The request for Trulance is not supported over the formulary alternative Amitiza (lubiprostone). The patient has had chronic constipation, and failed stimulant and osmotic laxatives, and an advanced agent (Linzess). The American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as Amitiza or Trulance should be used if non-pharmaceutical laxatives fail. Amitiza has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. Trulance has not demonstrated higher safety or efficacy than Amitiza in a direct controlled comparison. For these reasons, the use of Trulance is not supported over the use of Amitiza (lubiprostone) in this case.
Appeal type: Out-of-Network Service
Decision: Upheld

Diagnosis: Carcinoma of the parotid gland.
Treatment: Out of Network Proton Beam Therapy.
The insurer denied the Out of Network Proton Beam Therapy.
The determination is upheld.


This is patient with history of pT4aN0M0 adenoid cystic carcinoma of the right parotid gland status/post (s/p) resection and neck dissection. Out of network proton beam radiation therapy is requested. At issue is whether the proposed out-of-network health service is materially different from the alternate recommended in-network health service.
The proposed out of network health service is not materially different from the alternate recommended in-network health service. Proton beam radiation therapy is standard of care and required in the member's setting as photon-based radiation therapy cannot provide adequate safety/precision (the brainstem dose was unacceptable with the photon-radiation plan). The patient could receive proton beam therapy at an in-network treatment facility. There are not any extenuating circumstances present in the member's setting that would necessitate care at the out of network proton radiation facility. To this reviewer's knowledge, there is no difference between the in-network and out-of-network proton beam therapy.  They can both achieve similar safety/efficacy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II Occlusion. 
Treatment: Orthodontic Treatment. 

The insurer denied comprehensive orthodontic treatment. The health plan's determination is upheld.

The patient in question is a female with a Class II occlusion with 5 millimeter (mm) overjet and 6 mm overbite. The maxillary and mandibular arches have moderate crowding. She is treatment planned for orthodontics to correct her malocclusion. 

Comprehensive Orthodontic Treatment of the Adolescent Dentition is not medically necessary for this patient. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 5mm overjet, but this amount of overjet does not affect oral health related quality of life. If her teeth were aligned, it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. The requested Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent 300ML/2ML SC SOSY. 

The insurer denied the Dupixent 300ML/2ML SC SOSY. 
The denial is upheld. 

The patient is a female with atopic dermatitis, noted only on the face and eyelids. Provider mentions patch testing in documentation. Patient has tried and failed hydrocortisone, Tacrolimus and tobradex. The provider is requesting Dupixent.
The health plan denied the request due to lack of documentation of body surface area, treatment history, identification and elimination of triggering factors, and lack of trial and failure to systemic immunosuppressive therapy. 

No. The proposed treatment is not medically necessary. 

The patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The provider mentions contact dermatitis and patch testing, but there is no documentation this was performed, and Dupixent is not the most appropriate therapy for contact dermatitis. Dupixent can worsen contact dermatitis. Therefore, Dupixent is not medically necessary and appropriate for this patient. 

Yes, the health plan did act reasonably, with sound medical judgement and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematuria (blood in urine). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with a history of a traumatic brain injury that was admitted through the Emergency Room (ER) with gross hematuria, urinary retention and a urinary tract infection (UTI).  A catheter was placed for continuous bladder irrigation. Computed tomography (CT) imaging demonstrated bladder debris and bilateral hydronephrosis. The patients hematocrit was 24.9. The patients creatinine was 0.41. A prior cystogram showed a bladder mass. 

Day two, Intravenous (IV) antibiotics were continued.  The catheter was removed.  Intravenous fluids (IVF) were continued. 

On day three, the patient left against medical advice. Catheter reinsertion had been recommended. She was afebrile and hemodynamically stable throughout the stay. 

No. The proposed treatment is not medically necessary. 

The patient's gross hematuria resolved by the following day after admission.  Although she had hydronephrosis, the serum creatinine was normal.  She did not have complicating features such as abscess or immunosuppressed status.  Intravenous (IV) antibiotics can be administered at an observation level of care in an afebrile and hemodynamically stable patient. There were no compelling reasons to support an acute inpatient level of care as she was medically stable throughout the hospital stay. 

Yes, the health plan did act reasonably, with sound medical judgement and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Arrhythmia/Irregular Heart Rhythm. 
Treatment: Inpatient Stay. 

The health plan denied the inpatient stay. 
The reviewer has overturned in whole the health plan's determination. 

This patient was admitted to the hospital after two episodes of syncope. Cardiac monitoring showed frequent premature ventricular complexes (PVCs) and recurrent episodes of nonsustained, rapid polymorphic ventricular tachycardia that were initiated by short-coupled PVCs. Her family history was remarkable for unexplained sudden death in a first cousin. Her electrocardiogram was unremarkable; the QT interval was normal. During exercise stress testing she had frequent PVCs. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 54% (per cent) and was otherwise unremarkable. The patient was transferred to another institution for a cardiac magnetic resonance imaging (MRI) test that could not be performed at the original hospital. Upon admission to the second facility her blood pressure was 116/69 millimeters of mercury (mmHg) with a heart rate of 61 beats/minute. An electrocardiogram showed sinus rhythm with PVCs. An echocardiogram showed an LVEF of 50-55%. Continuous cardiac monitoring showed PVCs and some brief episodes of second degree atrioventricular (AV) block type I. The cardiac MRI was performed and was normal except for mildly decreased global left ventricular longitudinal strain. Electrophysiologic testing was performed; there was no inducible ventricular tachycardia. The patient had spontaneous PVCs of three different morphologies that were too infrequent for mapping. A subcutaneous implantable cardioverter defibrillator was implanted. Nadolol was prescribed. The patient was monitored. She had no significant arrhythmias and was discharged. 

An inpatient level of care was medically necessary. 

This patient presented with recurrent syncope due to rapid polymorphic ventricular tachycardia (PMVT), a life-threatening arrhythmia. A thorough evaluation for structural heart disease was required prior to implantation of an implantable cardioverter defibrillator. Careful and continuous monitoring with the ability to intervene emergently in the event of recurrent PMVT or cardiac arrest was needed and warranted an inpatient admission. 

Per the 2017 American College of Cardiology (ACC)/ American Heart Association (AHA) / Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. This patient's arrhythmia constituted such a condition and required an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain
Treatment: Pain Management
The health plan denied the requested outpatient pain injections as not medically necessary. 

The health plan's determination is upheld.

This is a female with a history of low back and claudication. She has had medications without relief. The neurologic exam shows 4/5 strength in the legs limited by antalgia. She has pain over her sacroiliac (SI) joint and positive provocative tests. Lumbar x-rays show degenerative changes and scoliosis. No lumbar magnetic resonance imaging (MRI) has been documented. The provider has recommended a left SI joint injection.
At issue is the medical necessity for the requested outpatient pain injections.

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

No. The patient has had no documentation of a course of physical therapy (PT). There was a note saying the patient was told she had a leg length discrepancy by PT, but no documentation of treatment. Additionally, after a course of physical therapy and the patient has continued symptoms, appropriate imaging should be performed, including images of the hips, SI joint and pelvis. An MRI of the lumbar spine would also be indicated, as the patient has neurogenic claudication and could potentially have spinal stenosis.