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

Diagnosis:  Hypogonadism
 
Treatment:  Aveed

The insurer denied the Aveed.  The denial was upheld. 
This is a male patient with a history of low testosterone, low luteinizing hormone, low follicle-stimulating hormone and normal prolactin.  He presented to his treating physician with complaints of fatigue.  He was given Aveed 750 mg intramuscular with a favorable response in terms of muscle tone. 
Reviewing the patient's lab work, the free testosterone level was 32.4 (35-155); his total testosterone level was 179; his luteinizing hormone level was 1.3; his follicle-stimulating hormone level was 1.5, and his prolactin level was within normal limits.  This first of all suggests secondary hypogonadism and not primary hypogonadism, as documented by the treating physician.  It would have been considered appropriate for this patient to have been sent to an Endocrinologist for further evaluation, including obtaining an AM cortisol level and an MRI of the pituitary gland.

Administration of Aveed every 12 weeks is as safe and as efficacious as testosterone enanthate for treatment of men with hypogonadism, (see reference 1).  The only benefit is lowered frequency of administration.  All methods of testosterone delivery improve testosterone levels in patients (see reference 2).

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for Aveed to treat primary hypogonadism is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental problems - Other
Treatment:  Dental/Orthodontic Procedure

The patient is a female with Class I occlusion, mild maxillary spacing, moderate overbite and mild overjet.  The proposed treatment is braces.  The subject to be determined is the medical necessity for braces and follow up visits.

The health plan's determination is upheld.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 8 with no auto qualifiers.  Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeter (mm) or greater and underbite 3.5mm or greater.  The case requires a score of 26 or more for treatment to be considered medically necessary.  The malocclusion in question does not meet the criteria to be classified as handicapping, and treatment would not be considered medically necessary.  Thus, braces and follow-up visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness & weakness  
Issue under review: Inpatient admission  

Determination: The inpatient admission was not medically necessary. 

The patient is an adult female with a history of diabetes, fibromyalgia and psychopathology who presented to the emergency ward with the complaint of right sided weakness and paresthesia.  At presentation, computed tomography (CT) scan was negative.  It was noted that when she was distracted she had antigravity strength but when tested directly she had weakness.  She was diagnosed with hemiplegic migraine.  

The patient presented with reported numbness and weakness.  She had inconsistent findings on examination and negative neuro-imaging.  The diagnostic studies, clinical evaluation, monitoring and treatment could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Low back pain
Treatment:  Hydrocodone Bitartrate-Acetaminophen Tablet 7.5mg/300mg 
The Hydrocodone Bitartrate-Acetaminophen Tablet 7.5mg/300mg is medically necessary.

The patient is a female who has been prescribed brand name Vicodin 7.5/300.  There is documentation that the patient has failed the required formulary alternative, hydrocodone 7.5/325.

The patient has not tolerated the requested formulary alternative, Norco (hydrocodone 7.5/325).  She has taken this medication in the past and had an adverse reaction.  It is not medically sound to go back on this medication.  Therefore, the alternative is brand name Vicodin (hydrocodone 7.5/300).  The Morphine equivalent dose remains the same, as does the potency.  Given the patient has failed generic hydrocodone, due to adverse reactions, the requested Hydrocodone 7.5/300 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision-macular degeneration.
Treatment: Home health care.
The insurer denied Increase in Personal Care Aide services, for a Live-in Per Diem, for 24 hours per day.
The denial is overturned in whole

The patient with a past medical history of oxygen dependent chronic obstructive pulmonary disease (COPD), asthma, macular degeneration with severe visual impairment, severe right knee osteoarthritis, decubitus ulcer, hypothyroidism, occasional urinary incontinence, hypertension, and gastroesophageal reflux disease (GERD) .
Yes, the requested treatment for the t patient to receive 24 hours per day 7 days a week of full-time supervision from her Personal Care Aide services aid is medically necessary and appropriate. 
With documentation provided by the patient's ophthalmologist, PCP and orthopedist, the patient would require more assistance with tasks of bed mobility, toilet use, transfer toilet, locomotion, walking, equipment management, bathing, personal hygiene and dressing lower body than assessed .
The patient has a new diagnosis of decubitus ulcer and per the PCP requires PCA service assistance overnight to prevent worsening bed sores as the patient is not able to change position in bed by herself. The PCP letter also noted the patient had become frailer requiring more help to accomplish ADL's.
Therefore, the personal care aide services are medically necessary for the live in per diem 24 hours per day 7 days per week.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal.
Durable Medical Equipment (DME) (including Wearable Defibrillators).

Diagnosis: Idiopathic toe walking.
Treatment: Bilateral Ankle/Foot Orthosis.
The insurer denied the custom fabricated Bilateral Ankle/Foot Orthosis. 
The health plan's determination is overturned. 

The patient is a young boy who walks on his toes. He is able to stand flat, and his ankle can be dorsiflexed above neutral, indicating that there is no fixed contracture of the gastrocnemius. His mother is concerned about his abnormal gait and feel that it may contribute to his frequent falls. An ankle-foot orthosis was recommended, in order to "break the habit" of toe walking. 

The Durable Medical Equipment: Bilateral Ankle/Foot Orthosis (custom fabricated) L1970 (x2), L2280 (x2), L2220 (x4) is medically necessary for this patient.
Idiopathic toe walking is a common gait abnormality in children, While it seldom causes the child much concern or functional difficulty, it is often of great concern to the parents, who seek intervention to correct it. Some children with idiopathic toe walking eventually develop a fixed equinus contracture that may require surgical treatment. Use of an AFO, designed to allow dorsiflexion but block plantar flexion beyond the neutral position, is commonly recommended. Other treatments sometimes used include botox injection and casting. The natural history of idiopathic toe walking for most children is spontaneous resolution, however some continue to toe walk into adolescence and adulthood, and therefore many people choose to treat this condition. No treatment has proven to be effective in all cases, however AFO's are often recommended and would be considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis; laparoscopic appendectomy performed.
Treatment:  Inpatient admission.

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

The patient is a male.  His medical and surgical histories were negative.  He presented to an emergency department with a three-to-six-month history of abdominal pain and with a diagnosis of "appendicitis", which was diagnosed on outpatient computed tomography. 

The patient's vitals were temperature 36.8, pulse 57, blood pressure 127/76, respirations 17, and oxygenation 96%.  His physical examination was benign.  On serum laboratories, his white-blood-cell count was 3.45.  The patient was admitted at an acute inpatient level of care.  He was made nil per os (NPO - nothing by mouth) and provided with intravenous fluids, antibiotics, analgesics, and antiemetics.  The patient underwent laparoscopic appendectomy; surgery and recovery were uncomplicated.  Having returned to his baseline health and function, the patient was discharged home with outpatient surgical follow-up. 

No, the proposed Inpatient admission was not medically necessary. 

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et al].  In fact, most patients can be discharged from the post-anesthesia care unit (the recovery room), precluding the need for inpatient admission [Mitchell et al; Dubois et al; Cash et al].  Therefore, for this patient, the admission at an acute inpatient level of care was not medically necessary; he could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness Or Weakness Of Numbness Of Right Side
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of hypertension, coronary artery disease and diabetes who presented to the emergency ward with the complaint of right arm and face numbness. At presentation her, National Institutes of Health (NIH) Stroke Scale was zero. She was admitted for possible transient ischemic attack (TIA). Neuroimaging was negative for stroke. 

No, the inpatient admission was not medically necessary. 

The patient presented with paresthesia and had a normal neurological examination. Current risk stratification guidelines for TIA do not support the need for acute inpatient admission. The diagnostic studies, treatment, monitoring and neurological consultation could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia.
Treatment: Mental Health Inpatient Stay.
The health plan denied the mental health inpatient stay. The health plan determination is overturned.

The case involves an adult male diagnosed with schizoaffective disorder and co-occurring substance use disorders (cocaine, cannabis, hallucinogens, and tobacco). He was admitted to acute inpatient level services with severe symptoms of psychosis with delusions, auditory hallucinations, disorganized thought behavior, and neglect of self-care and hygiene. Additionally, the patient has a history of non-compliance with treatment and non-adherence with medications and had not followed-up with his Act Team after discharge from the hospital.

The patient was admitted to acute inpatient level care after medical screening in the emergency department. The patient's treatment plan included safety-monitoring, access to group and milieu therapies, and resumption of medication to address the mood and psychotic disorder.  Medications were titrated as clinically appropriate, and he agreed to a Prolixin Decanoate injection with plans for continued use of the long-acting, injectable antipsychotic medication in concert with Prozac that was titrated to 20 mg.

Case management was working on a safe and clinically appropriate discharge plan. By discharge, the patient reported feeling better and denied suicidal ideation, morbid thoughts, or perceptual disturbance. The mood was euthymic. Sleep and appetite were okay. He did not show symptoms of drug withdrawal during his stay and had begun to attend groups focusing on illness education, social skills, and reality testing.

The health plan's determination of medical necessity is overturned as a whole.

Yes, the requested health service/treatment of Behavioral Health Inpatient Stay is medically necessary for this patient.
The patient's symptoms of psychosis and mood disorder, together with a continued risk of impulsive behavior, as well as non-compliance with treatment, prompted the necessity for continue acute inpatient level structure and monitoring through discharge.  The continued inpatient stay thru discharge was therefore clinically appropriate and medically necessary in order to provide active treatment and the continued inpatient level structure and 24-hour monitoring through the day of discharge when the patient had reached a level of stability that he could return to the community with ACT level services and with clinically appropriate follow-up and aftercare.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary incontinenece
Treatment: Incontinence supply; disposable liners 250 monthly
The insurer denied the Incontinence supply; disposable liners 250 monthly.
The denial is upheld. 

The patient is a female with a history of advanced dementia and chronic urinary incontinence. Due to impairments related to these conditions, she requires the use of incontinence supplies for treatment of this condition. Appeal review requested for potential approval of incontinence supply; disposable liners 250 monthly for improved treatment of this condition. 

No, the proposed treatment of incontinence supply; disposable liners 250 monthly is not deemed medically necessary. 

This is a female with a history of advanced dementia and chronic urinary incontinence. Due to impairments related to these conditions, she requires the use of incontinence supplies for treatment of this condition. However, review of the medical records indicates that the patient has already been approved for and receiving 300 disposable under pads and 250 disposable diapers per month which are sufficient to meet her current needs. For these reasons, the proposed treatment of incontinence supply; disposable liners 250 monthly is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuromuscular Disorder.

Treatment: Pontocerebellar Hypoplasia Panel (GeneDx).

The insurer denied the Pontocerebellar Hypoplasia Panel (GeneDx).

The denial was overturned.

This is a male patient who has been followed by neurogenetic service for global developmental delay as well as cerebellar hypoplasia. The appeal documentation indicated that the genetic testing was recommended to determine an underlying cause for global developmental delay and cerebellar hypoplasia. The documentation also indicated that the patient underwent chromosomal MicroArray as well as CDT for congenital disorders of glycosylation; both tests revealed normal results. The patient underwent pontocerebellar hypoplasia panel which included sequencing and deletion/duplication of 18 genes.  Additional documentation indicated that the patient was recommended for testing due to cerebellar hypoplasia on magnetic resonance imaging (MRI) which may be seen as either an isolated abnormality or as part of a syndrome. The patient seemed to have nonsyndromic cerebellar hypoplasia which may be caused by either a single gene disorder or congenital disorders of glycosylation. The results revealed a negative panel.

Based on the review of the medical record and literature, this patient does not have an isolated cerebellar hypoplasia, but also a clinical picture of developmental delay. Additional testing is considered medically necessary to confirm a diagnosis and formulate a treatment plan. Considering that this patient's cerebellar hypoplasia is likely part of a syndrome, genetic testing is considered medically necessary and appropriate for this patient's treatment and management.

Based on the above, the medical necessity for the Pontocerebellar Hypoplasia Panel (GeneDx) is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paronychia.

Treatment: Inpatient hospital admission.

The insurer denied the inpatient hospital admission.

The denial was upheld.  

This is a male patient with no medical history who presented to the Emergency Department (ED) with complaints of right 4th finger pain and swelling. The patient's presenting vital signs included: Temperature 97.9 F, Blood Pressure 131/85, and Pulse 96, Respiratory Rate 16, and Oxygen (O2) Saturation 98% on Room Air. The patient's laboratory results included CRP of 1.2. The patient was consulted by Plastic Surgery and Infectious Disease; he underwent a debridement by surgery. The patient was started empirically on intravenous antibiotics (i.e. vancomycin and Unasyn). The patient's x-ray of right hand showed soft tissue swelling of the fourth digit but no evidence of fracture or dislocation. Their impression was paronychia in the setting of recently clipping his nails.  The patient remained afebrile, hemodynamically and clinically stable.  The patient was discharged home with instructions to continue treatment (i.e., oral doxycycline and cephalexin) as an outpatient.       

According to documentation, the patient presented with right 4th finger swelling and pain. Otherwise, the patient was afebrile, hemodynamically stable with no evidence for systemic toxicity. The patient's laboratory values were unremarkable, and his x-ray did not show osteomyelitis.  Moreover, the patient did not have co-morbid conditions and did not require surgical intervention. The patient's treating physicians' clinical impression of this patient's condition was paronychia.  Based on these clinical findings, the patient did not fulfill criteria for acute inpatient admission.  Inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low back pain.
Treatment:  Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level; insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level; Interspinous process distraction device (implantable)(Superion Procedure).

The insurer denied insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level; insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level; interspinous process distraction device (implantable)(Superion Procedure).  The determination is upheld.

The patient has low back pain radiating into the right buttock, lateral thigh.  The patient has a prior history of a microdiscectomy at lumbar (L) 4-5.  The patient is utilizing multiple medications.  She has had injections as well as therapy.  The Superion procedure was requested.  At issue is whether the insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level; insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level; interspinous process distraction device (implantable)(Superion Procedure) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

It is not likely to be more beneficial than any standard treatment(s).  This patient has low back pain which radiates into the right buttock and lateral thigh and she has a prior history of a microdiscectomy at L4-5.

The use of an interspinous spacer for spinal stenosis as a minimally invasive, stand-alone procedure has shown high failure and complication rates.  There is no indication or support in the medical literature that such a device is more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The standard treatments include home exercise program, strengthening and conditioning classes, medication management, active modalities of physical therapy (PT) /chiropractic and possible injection treatments

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was overturned.

This is a male patient with a family history of asthma. He has been treated in the past with albuterol. The patient's mother reported they had brought a new cat home and the patient was experiencing some nasal congestion, coughing, difficulty breathing with increased respiratory effort. She decided to bring him to the emergency room (ER) for treatment. In the ER he was noted to be ill appearing with tachypnea and respiratory distress. On physical examination he was noted to have increased work of breathing with subcostal retractions and an expiratory wheeze. He was treated with an intramuscular dose of epinephrine, Benadryl and solumedrol with minimal improvement. He also received inhaled Atrovent; his blood testing was significant for an elevated lactic acid level of 3.7. He continued to have increased work of breathing and wheezing and the decision was made to admit him to the hospital with a diagnosis of anaphylaxis and status asthmaticus. The plan was to continue inhaled albuterol every 2 hours. After a period of medical stability he was discharged home with follow up instructions with a allergist/pulmonologist.

The insurer has denied this admission and stated that there was no documentation in the medical record to establish the need for admission to the hospital. The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The patient was treated appropriately in the ER for anaphylaxis and wheezing. When his respiratory distress, wheezing and cough persisted despite appropriate treatment in the ER, the admission to the hospital for ongoing treatment was consistent with the standard of care. He was not stable enough to be discharged to his home and the need for inhaled albuterol every 2 hours could not have been safely administered in the home setting.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is overturned.