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

Diagnosis: Orthopedic/Musculoskeletal-Back pain. 
Treatment: Surgical Services (All). 
The insurer denied reduction mammoplasty for medical necessity. 
The denial was overturned. 

This patient has complaints of back, neck and shoulder pain due to her large breasts. She has treated her condition with support bras and nonsteroidal anti-inflammatory drugs (NSAIDs). Her surgeon recommends breast reduction.
At issue is the medical necessity of reduction mammoplasty.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of reduction mammoplasty is medically necessary for this patient.
Breast reduction surgery is medically necessary for this patient. 
A study by Strong and Hall-Findlay found, "that reduction mammaplasty has a positive impact on a range of symptoms." "We advocate freedom for the surgeon to make a decision on potential benefits of surgery based around the needs of each individual patient." Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia. 
Therefore, the service/treatment of reduction mammoplasty is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-abdominal pain.
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female with a past medical history remarkable for hypertension, hyperlipidemia, heart failure, sarcoidosis, gastritis/duodenitis, irritable bowel syndrome (IBS) and esophageal dysmotility, who was admitted for abdominal pain and throat discomfort. The patient reported poor swallowing and inability to swallow oral intake resulting in 34 pound (lb.) weight loss in two months.

The patient was admitted for electrolyte disturbances due to poor oral intake, dysphagia, severe protein calorie malnutrition and esophageal dysmotility. The patient was treated with intravenous (IV) fluids, electrolyte supplementation, Pepcid, Ativan, Morphine and Zofran. Speech Language Pathologist (SLP) evaluation was ordered  but was deferred until gastrointestinal (GI) evaluation. Review of laboratory findings revealed potassium of 5.3 and sodium of 129. The following day electrolytes demonstrated significant improvement with sodium of 135 and potassium of 3.4. GI evaluation and Swallow evaluation were subsequently done, and patient was able to tolerate a pureed diet. The patient was discharged with outpatient GI follow up. Physical therapy (PT) evaluation was done with recommendations for skilled facility, but the patient opted for home therapy. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

Yes, an inpatient stay was medically necessary. This patient presented with significant electrolyte abnormalities in the setting of chronic malnutrition, dysphagia and inability to maintain oral hydration. The patient required inpatient level of care for IV hydration and electrolyte stabilization. The patient presented with moderate hypokalemia in the setting of abdominal pain, dehydration and poor oral intake. Though she did not have severe hypokalemia, the level of 2.8 was severe enough to put her at risk for fatal cardiac arrhythmias if untreated in the setting of persistent dysphagia. Given that she had persistent hypokalemia on the following day and poor oral intake, it was reasonable to expect that she might require two midnights in the hospital for hydration and aggressive potassium repletion to avoid fatal cardiac arrhythmias. Her history of esophageal dysmotility, IBS, gastritis and duodenitis also puts her at risk for failure of oral intake. This patient was appropriate for acute inpatient level of care. Treating this patient with severe protein calorie malnutrition, significant weight loss and clinical dehydration with poor oral intake and persistent electrolyte abnormalities creates risks for worsening symptoms and potential for arrhythmia at the observation level of care. Inpatient level of care was warranted for IV hydration, treatment of abdominal pain with IV narcotics (morphine) and electrolyte abnormalities.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Back Pain. 
Treatment: Pain Management. 

The health plan denied the requested pain management treatment as not medically necessary. 

The health plan's determination is overturned. 

The patient is a female with low back and right leg pain. Right lumbar (L) 4-L5 (L4 root), L5-sacral (S) 1 (L5 root) transforaminal epidural steroid injections (TFESI) are proposed.
The proposed procedure was initially denied because cross-sectional imaging of the spine which correlates with the clinical scenario was not reported. 

At issue is the medical necessity of the requested treatment. 

I overturn, in whole, the health plan's determination of medical necessity. 

Yes, based on the initial denial and submitted clinical material that documents the missing criteria, the proposed TFESI is considered medically necessary for this patient. The lumbar magnetic resonance imaging (MRI) correlates with the symptoms and proposed procedure. The lumbar MRI performed by report describes right L4-5, right L5-S1 foraminal disc protrusions effacing the exiting L4 and L5 nerve roots. 

In short, the proposed procedure was initially denied due to lack of documentation of cross-sectional imaging of the lumbar spine with clinical correlation of the patient's symptoms. 

The clinical material submitted with this appeal includes the report of a lumbar MRI performed, which reports nerve root impingement at the sites of the proposed procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicide attempt: multiple Injuries (toe and head). 
Treatment: Inpatient admission. 

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

The patient is a female. Her medical history includes schizophrenia. 

The patient attempted suicide by jumping out of a second-floor window. Her vitals were: temperature 36.3, pulse 97, blood pressure 117/75, respirations 18, and oxygenation 98%. Trauma work-up, which included computed tomography, demonstrated: 1) scalp laceration; 2) right second toe fracture; and 3) right fifth toe laceration. In the emergency room, the scalp and toe lacerations were treated/closed; and the patient's wounds were dressed. 

The patient was admitted at an acute inpatient level-of-care for "Trauma and Concussion secondary to suicide attempt". Her cervical (c)-spine was cleared. Having demonstrated continued stability, the patient was transferred to an inpatient psychiatric unit. 

No, the proposed treatment was not medically necessary. 

Trauma work-up demonstrated three findings -- 1) scalp laceration; 2) right second toe fracture; and 3) right fifth toe laceration. The lacerations were repaired in the emergency room; the fracture did not require intervention. Therefore, particularly in the absence of instability, complications, or significant anatomic or physiologic derangements, the patient did not have need for admission at an acute inpatient level-of-care.  The patient could have been treated at a lower level-of-care or been referred to psychiatric treatment. 

Guidelines from the Eastern Association for the Surgery of Trauma caution against over-treatment -- "Triaging patients into a tiered trauma response in-hospital can be very effective and reduce unnecessary resource utilization while maintaining quality of care." [EAST]. 

Particularly in the absence of instability, complications, or significant anatomic or physiologic derangements, the patient did not have need for admission at an acute inpatient level-of-care; the patient could have been treated at a lower level-of-care or been referred to psychiatric treatment. 

Guidelines from the Eastern Association for the Surgery of Trauma caution against over-treatment -- "Triaging patients into a tiered trauma response in-hospital can be very effective and reduce unnecessary resource utilization while maintaining quality of care." [EAST].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth. 
Treatment: D6010 Implant Placement, Tooth 14, 3 and 4; 
D6057 Custom Abutment, Tooth 14, 3, and 4; 
D6058 Abutment Supported Porcelain/ Ceramic Crown, Tooth 14, 3 and 4 

The insurer denied the D6010 Implant Placement, Tooth 14, 3 and 4; 
D6057 Custom Abutment, Tooth 14, 3, and 4; 
D6058 Abutment Supported Porcelain/ Ceramic Crown, Tooth 14, 3 and 4. 

The denial is overturned. 

The patient is a female requesting dental benefits for the placement of implants, custom abutment, abutment supported porcelain/ceramic crowns--teeth #3, 4, and 14. 

The patient presents with all upper molars missing and upper right first premolar (tooth #4) also missing. 

Yes, the proposed treatment of implant placement, custom abutment and abutment supported porcelain/ceramic crowns are medically necessary. 

Digestion starts in the mouth with the ability of the foods we eat being mechanically broken down/ mashed by the molar teeth, as is evident in the patients x-rays; she does not have any of her upper molars and is in need of replacements. 

Furthermore, based on the patient's physician's reports regarding her nutritional health status-- the basic need for the proper ability to chew and digest her food would be the first essential step in providing better nutrition for the patient. 

The health plan asked for the reasoning as to why a denture would not work; the documents supplied state that this patient has a very sensitive gag reflex. Therefore, she would not be able to comfortably wear an upper denture. 

While there are ways to manage this reflex during dental procedures, the difference between the ability to manage during treatment as opposed to wearing the actual denture on a regular basis must be considered. 

Typically there are three options for tooth replacement: 1) Dentures, 2) Fixed Bridgework, and 3) Implants, which consists of the three components as part of the implant system (Implant, custom abutment, abutment supported porcelain/ceramic crown.) 

Because this patient does not have any teeth present distal to the missing teeth she is not a candidate for option #2-Fixed Bridgework. 

The dental clinical summary states that this patient has a hypersensitive gag reflex system --this will preclude her from being a candidate for denture fabrication and tolerating the use of an upper denture. 

Therefore, the patient now only has one option for replacement, which is the Implant system--option #3. 

Based on this patient's clinical circumstances the implant treatment is necessary for the best possible option to restore a level of function that can benefit the patient's health.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Acute Myeloid Leukemia.
Treatment: Xospata 40 MG OR TABS
The insurer denied Xospata 40 mg OR TABS.
The determination is overturned.

The patient has a diagnosis of acute myeloid leukemia (AML) with FLT-3 internal tandem duplication (ITD) gene mutation. As per the medical records he has been able to complete only 4 of his 5 planned chemotherapy cycles due to toxicity. In addition to chemotherapy, he has been treated with Midostaurin, a first generation tyrosine kinase inhibitor targeting the FLT3 gene alteration, however, due to toxicity (prolonged Qtc), the drug was discontinued. His oncologist is requesting authorization to replace Midostaurin with Gilteritinib, a second generation tyrosine kinase inhibitor (TKI). At issue is whether the Xospata is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Gilteritinib (Xospata) is likely to be more beneficial than any standard treatment for the patient's disease.
AML is the second most common type of leukemia in adolescents and young adults. About 30% of patients with AML harbor a FLT3 gene alteration which is unfavorable and carries a poor prognosis. FLT3 is a Class III tyrosine kinase, expressed primarily in hematopoietic cells, that plays a role in cell survival and proliferation. The current standard of care for treatment of FLT3-ITD mutated AML is intensive chemotherapy with the addition of a tyrosine kinase inhibitor (TKI) that targets FLT3 followed by hematopoietic stem cell transplant in 1st remission if a donor is available. Midostaurin is a first generation TKI that received Food and Drug Administration (FDA) approval for treatment of FLT3-ITD-mutated AML in 2017. Subsequently, a number of second generation TKIs were developed with higher affinity for FLT3 targeting, less off-target effects, and therefore, greater potency and more favorable toxicity profile. Of the 2nd generation TKIs, Gilteritinib was found to be particularly well-tolerated and effective in the ADMIRAL study and gained FDA approval in adults in 2018. For this reason, the the Childrens Oncology Group (COG) selected Gilteritinib for treatment of FLT3-ITD-mutated AML in the current active AML clinical trial (AAML1831).
This patient was appropriately treated with a FLT3-targeting TKI that was available and approved for his age, however, he did not tolerate it and developed cardiac toxicity. As his primary oncologist noted, adolescents are commonly treated in a similar fashion and with the same drugs as adults. Gilteritinib is an appropriate choice of TKI for this patient as the second generation TKIs are more tolerable and have been shown to have improved efficacy. Furthermore, early phase studies have demonstrated safety in children leading to is selection for the current ongoing COG AML clinical trial. The patient under review is particularly high risk for relapse due to his unfavorable FLT3 mutation and truncated chemotherapy course (due to toxicity). It would be imperative for him to continue to receive targeted TKI therapy that he can tolerate safely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ureterovesical Junction Stone

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is the case of a female patient with a history of nephrolithiasis who presented to the Emergency Department (ED) with complaints of right flank pain for 3 days. Computed tomography (CT) scan revealed 7 millimeter (mm) proximal right ureteral stone and 3.5 mm left ureterovesical junction (UVJ) stone. The patient passed a left UVJ stone. The pain returned, so she return to ED. Renal ultrasound now showed 1 cm (centimeter) right UVJ stone with right hydronephrosis, and human chorionic gonadotropin (HCG) level of 27. The patient did not wish to continue the pregnancy. She was admitted for pain control, and had a medical abortion with mifepristone. After termination of pregnancy, the patient had lithotripsy, and stent placement. The patient was discharged home with multiple out-patient follow-up visits. The insurer has denied coverage for the full hospital admission as not medically necessary. They noted lack of fever, lack of decline in renal function, no vomiting. 

Per MCG Health (24th) Renal Colic + Kidney Stone RRG, patient fails to meet clinical indications for admission to inpatient care. These include, but are not limited to:

A.	Hemodynamic instability
B.	Acute renal failure
C.	Bilateral obstruction
D.	Severe, persistent vomiting
E.	UTI (urinary tract infection) identified
F.	Stone removal procedure needed requiring inpatient admission (patient had cystoscopy, right ureteroscopy, laser lithotripsy, and stent placement which is an out-patient procedure)

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. The full hospital is not considered medically necessary for this patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic Fibrosis.
Treatment: Pre-service request for genetic testing services (procedure code 81403).
The insurer denied coverage for Pre-service request for genetic testing services (procedure code 81403).
The denial is overturned.

The patient is a female who underwent genetic carrier screening in early pregnancy and was found to be a carrier for delta F508 cystic fibrosis. Her male partner underwent carrier testing and was also found to be a carrier for cystic fibrosis with a different and less common mutation.  Amniocentesis for cystic fibrosis testing of the fetus has been recommended by her Obstetrician.

The medical records and medical literature were thoroughly reviewed. cystic fibrosis is the most common life-threatening, autosomal recessive condition in the non-Hispanic white population. The disease incidence is 1 in 2,500 individuals in the non-Hispanic white population and considerably less in other ethnic groups. It is a progressive, multisystem disease that primarily affects the pulmonary, pancreatic, and gastrointestinal systems but does not affect intelligence. The current median predicted survival is approximately 42 years, with respiratory failure as the most common cause of death. More than 95% of males with cystic fibrosis have primary infertility with obstructive azoospermia secondary to congenital bilateral absence of the vas deferens. Cystic fibrosis is caused by mutations in the cystic fibrosis transmembrane regulator gene, located on chromosome 7. Two copies of deleterious mutations in this gene cause cystic fibrosis. The patient and her partner are both carriers for cystic fibrosis. This diagnosis confers a 25% risk of the fetus to be affected by the disease. The analysis of amniotic fluid is planned, to locate the couple's specific cystic fibrosis mutations using a targeted assay. Therefore the testing is medically necessary. 

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 pre-service request for genetic testing services (procedure code 81403) is reversed.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia.

Treatment: increase to personal care aide (PCA) Level 2 services for a total of 12 hours per day, 7 days per week for a total of 84 hours per week.

The insurer is denied coverage for increase to personal care aide (PCA) Level 2 services for a total of 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is overturned. 

This female patient has a history of dementia, type 2 diabetes mellitus, hypertension, rheumatoid arthritis, fibromyalgia, gastroparesis, degenerative cervical disc disease, brachial neuritis or radiculitis, cervical spine stenosis, restless leg syndrome with complaints of left sided neck pain radiating down to her left upper extremity. The patient was hospitalized due to diagnoses of hypertension, acute kidney injury and neck pain. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives in alone in a one bedroom apartment on the 11th floor of an elevator access building. Her overall self-sufficiency has deteriorated, and the patient requires increased assistance with her activities of daily living and instrumental activities of daily living due to increased weakness and limited range of motion. She is totally dependent for meal preparation, ordinary housework, managing stairs, and shopping. The patient needs maximum assistance with managing finances, managing medications, transportation, dressing her upper body, dressing her lower body, walking, locomotion and toilet transfer. The patient is occasionally bladder and bowel incontinent. She needs extensive assistance with toilet use and bed mobility. The patient needs limited assistance with eating. The patient uses an assistive device for locomotion indoors. An increase to personal care aide (PCA) Level 2 services for a total of 12 hours per day, 7 days per week for a total of 84 hours per week is being requested.

Considering the patient's medical history, and functional status, it is apparent that the patient needs substantial assistance with IADLs (Instrumental activities of daily living) and ADLs (Activities of daily living). Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance for daily activities. The patient needs assistance for IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes all meals and routine household tasks; routine morning and evening ADLs (e.g. bathing, dressing, personal hygiene); and unscheduled activities that occur throughout the day, including toileting related tasks, and mobility (transfers, walking). Without adequate assistance, the patient is at risk for injury due to falls/household accidents; skin injury due to inadequate toileting and incontinence care; inadequate pain management; risk of nutritional decline.

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 inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mild obstructive sleep apnea.

Treatment: An oral appliance, code E0486, for the treatment of obstructive sleep apnea.

The insurer denied coverage for an oral appliance, code E0486, for the treatment of obstructive sleep apnea.

The denial is overturned. 

This is a male patient who had complaints of irregular sleep and disordered breathing when he slept on his back. He was evaluated and noted that he would have a moderate chance of dozing while watching television or lying down to rest in the afternoon. He had a slight chance of dozing while sitting quietly after lunch. His body mass index was 30.12. He had symptoms consistent with sleep apnea. He was snoring at night and he was tired all day. A portable home sleep study revealed an apnea-hypopnea index of 6.2 events/hour. It was consistent with the diagnosis of mild sleep apnea. The events were mostly obstructive in nature. The recommendations due to the home sleep study included doing nothing, losing weight, continuous positive airway pressure (CPAP), or a dental appliance. The claimant signed a CPAP intolerance/noncompliance affidavit and noted he was unable to sleep with the CPAP mask and equipment in place.

The appeal letter noted the claimant had been evaluated by a sleep specialist. The patient had a diagnosis of mild sleep apnea and it was advised and recommended that an oral appliance would be satisfactory to treat his sleep apnea. He refused to use CPAP. A complete dental and jaw examination was performed when the patient initially entered the dental practice. A subsequent comprehensive examination to be-evaluate his dental and temporomandibular joint health was performed prior to making his sleep apnea device.

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

The requested oral appliance, code E0486- oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment, for treatment of obstructive sleep apnea is considered medically necessary for this patient.

Oral appliance is medically necessary to treat this patient's mild obstructive sleep apnea since he was not able to use CPAP.

The insurer's denial of coverage for an oral appliance, code E0486 for treatment of obstructive sleep apnea is overturned. Medical necessity is substantiated.