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

Diagnosis: Right Knee Pain.
Treatment: Right Knee Arthroscopy.

The insurer denied Right Knee Arthroscopy. The determination is overturned.

The patient has a complaint of right knee pain. The records document that the patient had experienced right knee pain over a duration of a few years without any acute injury or trauma. She also denied any mechanical symptoms in her knee with no history of locking or giving way. Plain radiographs obtained revealed no degenerative changes, no loose bodies and well preserved joint spaces. On examination, the patient had a palpable mass along the lateral joint line of the affected right knee. A magnetic resonance imaging (MRI) scan of the right knee was ordered which revealed a multi-lobulated 5 x 2 centimeter (cm) para-meniscal cyst located adjacent to the lateral meniscus. The MRI confirmed that the menisci, collateral ligaments and cruciate ligaments were intact and normal. A follow up visit documented that the patient had persistent right knee pain in the lateral aspect of the knee. The provider opined that the right knee MRI scan showed a degenerative tear in the anterior horn of the lateral meniscus with the cyst originating at this tear site. His recommendation was for right knee arthroscopy for partial lateral meniscectomy versus repair as well as para-meniscal cyst excision. The right knee arthroscopy procedure was denied by the health plan and is being appealed.

The requested health service/treatment is medically necessary for this patient based upon the provided medical records which document persistent symptoms for the patient despite conservative treatment and the current, peer-reviewed literature which endorses surgical intervention to include knee arthroscopy and cyst excision for large para-meniscal cysts that are symptomatic. The provided records document that this patient had a long history of right knee pain. She had attempted reasonable conservative treatment measures to include oral medications and activity modifications which did not alter her level of pain in the right knee. She had a right knee MRI scan which confirmed a large lateral para-meniscal cyst. The treating physician opined that the knee MRI demonstrated a lateral meniscus tear as the source of the large cyst. The records document that the patient attempted reasonable conservative treatment for this condition which do not resolve her symptoms of knee pain and limitation of function. Based upon the provided records, the medical necessity for the proposed procedure is established.
The proposed surgical intervention is also consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Cowden and colleagues in the Journal of Knee Surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cannabinoid hyperemesis syndrome.
Treatment:  Inpatient admission.

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

This is a male patient with a past medical history of gastroesophageal reflux disease (GERD) and marijuana hyperemesis syndrome, who presented to the emergency department (ED) with complaints of vomiting.  The patient was admitted to the Medical Surgical unit with a diagnosis of cannabinoid hyperemesis syndrome. 

The patient presented with vomiting.  He had a history of multiple previous visits for cannabinoid induced hyperemesis.  He was afebrile, and his vital signs were stable.  The abdominal exam was benign.  The renal function was normal. Intravenous (IV) hydration, Zofran and proton pump inhibitor (PPI) therapy were given.

Clinical indications for admission for vomiting (Milliman Care Guidelines (MCG) M-370) include gastrointestinal obstruction, a significant metabolic derangement, hemodynamic instability, severe electrolyte abnormalities, and acute renal failure.  The patient did not have these conditions.

The patient had vomiting due to cannabinoid use.  IV hydration, Zofran, and PPI therapy could have been given with observation status.  He did not meet MCG criteria for admission for vomiting.  His diet was able to be advanced.  The healthcare plan acted reasonably and with sound medical judgment.  An inpatient admission was not medically necessary. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Moderate to Severe Psoriatic Arthritis.
Treatment:  Otezla 30MG (milligram) Tablet.

The insurer denied the Otezla 30MG Tablet.  The denial is overturned. 

The patient is a woman moderate to severe psoriasis for whom Otezla is requested.  She also has joint pains.  Her skin lesions worsened with steroid treatment.  She has a family history of lupus.

Yes, the treatment with Otezla is medically necessary.

The patient has moderate to severe psoriasis for which Otezla is medically appropriate and necessary.  She has diabetes and abnormal liver function tests, which make her a poor candidate for biologic therapies and conventional systemic agents.  Diabetes carries a higher risk of infection, and Otezla does not have any side effects that would put her at risk, whereas Enbrel and Humira do (warning about infection).  She is also not a great candidate for TNF (tumor necrosis factor) alpha inhibitors, due to her family history of connective tissue disease.  Due to the abnormal liver function tests, she is not a candidate for methotrexate.  Due to her age and childbearing potential, she is not a candidate for acitretin.  Cyclosporine is not an appropriate long-term medication for psoriasis and carries a risk of side effects that are not acceptable for long term management of psoriasis, especially in a patient with diabetes and abnormal liver function. 

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (Celgene).  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA), as well as the treatment of patients with moderate to severe plaque psoriasis (Celgene).  The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Trauma/Injuries. 
Treatment:  Ambulance. 

The insurer denied the air ambulance transport.  The denial was overturned in whole.

The patient is a male, who sustained a fall off of a ladder while attempting to access a tree stand for hunting.  His fall was from a height of 15 feet.  This resulted in significant deformity of his right femur and back pain.  This accident occurred in a very remote area of the woods while the patient was hunting.  The patient was then brought via air ambulance transport to University of Rochester Medical Center as a Level 1 trauma.  He subsequently underwent emergent surgery for his femur.  The patient's health plan denied the air ambulance transport for the patient as not medically necessary.  At issue in this case is the medical necessity of the air ambulance transport of this patient from the location of the accident to the hospital for definitive treatment. 

The health plan's determination is overturned, in whole.

The requested Air Ambulance Transportation Services was medically necessary for this patient.  This determination is based upon a review of the provided medical records and the current, peer-reviewed orthopedic literature with respect to comminuted femur fractures and falls from a height.

This patient sustained a fall from a height of 15-20 feet sustaining a severe limb threatening injury to his right femur.  The records also document that this injury occurred in a very remote area of the woods that was not accessible by land ambulance.  The air ambulance was medically necessary for this transport of this patient because of the nature of his right leg injury and the possibility of internal injuries from the fall.  The patient subsequently underwent placement of an intra-medullary rod for fixation of the femur fracture, which is consistent with the recommendations of the current, peer-reviewed orthopedic literature, as documented by El-Menyar and colleagues.  An L1 fracture of his lumbar spine was also discovered upon the trauma evaluation at the hospital.

The air ambulance was medically necessary for transport to the nearest level 1 trauma center where the patient was evaluated, resuscitated, and subsequently treated for his femur fracture and an L1 transverse process fracture.  The remoteness of the location of the accident made standard land ambulance impossible.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Braces.
The insurer denied the braces. 
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits.

Yes, the braces are medically necessary.  The patient has anterior crossbites (reverse bites) of her lower left and right canines. This is an "automatic qualifier" according to the handicapping index scale. Orthodontic treatment to correct this is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malignant neoplasm of thyroid gland

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is overturned. 

This is a female patient with a history of a malignant neoplasm of thyroid gland, hyperlipidemia, osteoarthritis of shoulder, history of a pulmonary embolus, degenerative arthritis of cervical spine, bilateral shoulder region arthritis, migraine headache, moderate major depression, substance abuse, leukopenia, obesity, glaucoma, and an abnormal electrocardiogram (EKG). The patient presented to the hospital for a scheduled thyroidectomy.

On admission, the patient was found to have an abnormal EKG, and a body mass index (BMI) of 32, indicative of obesity. She underwent a total thyroidectomy with limited central compartment neck exploration which lasted for 1 hour 39 minutes (99 minutes).  She had an American Society of Anesthesiologists (ASA) score of 3. 

Peer reviewed literature documents an increased risk for postoperative complications of obese patients as was documented for the patient who was found to have a BMI of 32, which is noted as obesity. Prolonged anesthesia time such as the 1 hour 39 minutes which the patient underwent has been documented in peer reviewed literature as increasing postoperative risk and an increasing length of stay. The patient was in the 4th quintile of anesthesia time which was found to have the higher risk of complications. The patient had other serious risk factors including the history of a pulmonary embolus, on admission an abnormal EKG, and an ASA score of 3. The patient had multiple indications for the prolonged hospital stay which included an ASA score of 3, obesity with a BMI of 32, abnormal EKG, increased anesthesia time and history of a pulmonary embolism. 

The health care plan did not act reasonably nor with sound medical judgment nor in the best interest of the patient, as the patient needed the observation time because of her multiple serious risk factors. The inpatient admission was medically necessary as she had numerous risk factors which have been documented to be associated with an increased hospital stay.

The denial should be overturned as the patient had numerous indications any one of which would justify a prolonged hospital stay.

The carrier's denial of coverage for the inpatient admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parotidectomy with sternocleidomastoid muscle flap
Treatment: Muscle Flap To Right Cheek ( 15733 -sternocleidomastoid)
The insurer denied the Muscle Flap To Right Cheek ( 15733 -sternocleidomastoid).
The denial is overturned. 

The patient is a female with history of parotidectomy with sternocleidomastoid muscle flap (15733) to the tumor bed simultaneous with parotidectomy.  As outlined by the physician, the flap was used to prevent Frey's syndrome.  

Yes, the Sternocleidomastoid muscle flap to the right cheek at the time of parotidectomy (15733) was medically necessary.

As noted in the physician's appeal, the flap is designed to prevent Frey's syndrome. It serves a functional role of preventing cross connection of parasympathetic nerves of sweat glands with the parasympathetic innervation of the parotid gland.  Thus, the flap as performed was medically necessary and was functional.  Though this flap fills some of the tumor defect, its primary function is to provide a barrier to nerve penetration to the skin elements.

The health plan's denial did not take into account the functional role that this flap plays.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Cramping And Bloddy Stools
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with history of GERD (gastroesophageal reflux disease), who presented to the emergency department with abdominal pain and five episodes of diarrhea, and after the last bowl movement, she reported seeing blood in the toilet bowl. She went to see her gastroenterologist who advised her to go the emergency department.  In the emergency department. she was hemodynamically stable and afebrile. The CT (computerized tomography) scan of the abdomen revealed thickening of the splenic flexure with surrounding fat stranding, and mild thickening of the GE (gastroesophageal) junction. The CBC (complete blood count) revealed normal Hb/HCT (hemoglobin/ hematocrit) and WBC (white blood cells):13.3. The Chem panel was normal. 

In the emergency department, she was given Nexium 80mgIV (intravenous), and Ceftriaxone 1g IV (intravenous) and Flagyl 500mg IV (intravenous). She was made NPO (nothing by mouth), started on IV(intravenous) fluids, and continued on Ceftriaxone 1g IV (intravenous) bid (twice a day), and Flagyl 500mg IV (intravenous) q12hrly (every), and started on Protonix 40mg IV(intravenous) bid (twice a day). She was given Zofran IV (intravenous) prn (when necessary) for nausea. The stool studies were sent for further evaluation of acute diarrhea. The next day, she was clinically stable and discharged home on Cipro and Flagyl and advised to follow up with a gastroenterologist on an outpatient basis.

No, the proposed acute level of care for the management of this patient condition was not appropriate and medically necessary. 

The presented with one day history of abdominal pain, and diarrhea with some blood in the stools. She was hemodynamically stable, and afebrile and her Hb/HCT (hemoglobin/ hematocrit) were normal. Her abdominal examination was normal with no signs of peritonitis. The stool studies were sent to rule out infectious colitis. She had mild leukocytosis and was empirically started on IV (intravenous) antibiotics for the management of mild colitis seen on CT (computerized tomography)  scan of the abdomen done on the day of her admission. She remained hemodynamically stable over the next 24hrs and tolerated the diet next day and discharged home on oral antibiotics and with the outpatient follow up with the GI (gastroenterologist). Given this clinical scenario and benign hospital course with no recurrence of active bleeding requiring blood transfusion or any endoscopic intervention, the patient could have appropriately managed under lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myofascial pain
Treatment: Dorsal root ganglion stimulation (DRG) to treat myofascial pain
The insurer denied the dorsal root ganglion stimulation (DRG) to treat myofascial pain.
The denial is upheld. 

The patient has history of complex regional pain syndrome left lower extremity status post lumbar sympathetic blocks x2 (times 2) with 30% relief for one week and diagnosed as sympathetic mediated pain. Patient also has history of right buttock pain radiating to left lower extremity that started several years ago. The pain is affecting the patient's social life and daily activities. The patient continues to do home exercises. The patient received several injections for pain with temporary relief. The patient has tried physical therapy, ibuprofen, meloxicam, Flexeril, and gabapentin. Examination was positive for tenderness in the back, piriformis also tender, left buttock sensitive, and allodynia. The patient was deemed to have normal strength. The patient is diagnosed as complex regional pain syndrome left lower extremity and was advised percutaneous implantation of 2 leads for dorsal root ganglion trial.

MRI (magnetic resonance imaging) of the lumbar spine per provider showed minimal changes at L4-5 (lumbar vertebrae) with stenosis that does not explain the left hip pain.

The patient's provider cleared the patient for dorsal root ganglion trial.

No, the health plan should not cover the proposed treatment. 

No, the requested procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's condition.

The patient has history of left lower extremity pain and diagnosed as complex regional pain syndrome. The patient has tried pain medications, injections, and physical therapy with temporary benefit. MRI lumbar spine was reviewed with the patient, however official findings of the report were not submitted. The patient does not fulfill the criteria for complex regional pain syndrome as per the Budapest criteria. The patient also has diagnosis of sciatica; examination does not correlate with radiculopathy. Psychology assessment prior to the dorsal root ganglion trail was not included.

As per the peer-reviewed medical literature, Neuromodulation of the dorsal root ganglion appears to be an effective option for selective targeting of painful areas in complex regional pain syndrome. Since the patient does not fulfill the diagnostic criteria for complex regional pain syndrome or the requested dorsal root ganglion trial, the health plan should not cover the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myofascial pain
Treatment: Dorsal root ganglion stimulation (DRG) to treat myofascial pain
The insurer denied the Dorsal root ganglion stimulation (DRG) to treat myofascial pain. The denial is overturned. 

The patient is a female with presumed complex regional pain syndrome of the left lower extremity. She has failed multiple injections including epidural injections, piriformis injection, SI (serum iron sacroiliac) joint injection. She has had two lumbar sympathetic nerve blocks with appreciable improvement, however temporary. She has done physical therapy and she has tried various medications.

Yes, the requested dorsal root ganglion stimulation is likely to be more beneficial than any standard treatment or treatments for the insured's condition. The patient has failed conservative treatments for complex regional pain syndrome. She has done physical therapy, which made her pain worse. She has been seeing a psychologist and a psychiatrist. She has been taking NSAIDs (nonsteroidal anti-inflammatory drugs) and various pain medications. She has had numerous injections, including lumbar sympathetic nerve blocks. The presumptive diagnosis of CRPS (complex regional pain syndrome) has been somewhat confirmed with her response to lumbar sympathetic nerve blocks. At the very least it can be said that she does have sympathetic mediated pain. Once conservative treatments have failed and no other options have been helpful, spinal cord stimulation is typically recommended. However, over the last few years, increasingly strong data has come out supporting dorsal root ganglion stimulation to be superior to traditional spinal cord stimulation. In fact, it has been shown to be superior to traditional spinal cord stimulation in a few conditions, specifically complex regional pain syndrome. There is also some evidence for its superiority already in conditions such as Pelvic Pain, Pudendal Neuralgia, Amputee Pain, Post Hernia Pain, Post Mastectomy Pain, and Post Herpetic Neuralgia. This has been shown to be standard in randomized control trials with up to 12 months follow-up. Given that the requested procedure is FDA (Food and Drug Administration) approved and has been shown in peer-reviewed literature to be superior to traditional spinal cord stimulation, the requested dorsal root ganglion stimulation is medically appropriate for the above patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hiccups And Vomiting (alcohol withdrawal). 
Treatment: Inpatient admission. 

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

The patient is a male with a history including polysubstance abuse. He presented to the ED (emergency department) requesting detox. He had hiccups and vomiting for the past three days associated with leg swelling and headaches. 

The patient's VS (vital signs) were as follows: Temperature 98, Pulse 77, Respiration rate 19, Blood pressure 135/91, Pulse oximetry 96%. His exam was unremarkable. His labs were as follows: Na (sodium) 140, K (potassium) 4.3, BUN/Cr (blood urea nitrogen/creatinine) 14/.8, WBC (white blood count) 2.9, H/H (hemoglobin/hematocrit) 14.2/42.9, Plt (platelets) 93. 

The patient was admitted. Plan of care included CIWA (clinical institute withdrawal assessment) protocol. 

Admission day 1, the patient's vital signs were stable. He was feeling better. CIWA (clinical institute withdrawal assessment) 1 - 12. CPK (creatine phosphokinase) was 285. He was requesting Suboxone, as he was feeling withdrawal starting. He was continued on CIWA (clinical institute withdrawal assessment) protocol. He was continued IVF (intravenous fluids) at 100 cc/hr (cubic centimeters per hour). CXR (chest x-ray) revealed NAD (no active disease). 

Admission day 2, the patient's vital signs were stable. He was feeling better. The plan was to continue CIWA (clinical institute withdrawal assessment) protocol, and continue Suboxone. Repeat platelets were 49. He was cleared by psychiatry. 

Admission day 3, the patient was cleared for discharge. 

No, the Inpatient admission was not medically necessary. 

This patient was admitted after presenting for alcohol detox. The patient did not have active comorbid conditions. The patient was hemodynamically stable and afebrile. He did not have tachycardia or arrhythmia. He did not have persistent vomiting, delirium, seizures, or gross tremor. Labs were remarkable for low WBC (white blood cell) and platelet count. The patient was admitted with plan for IVF (intravenous fluids) and CIWA (clinical institute withdrawal assessment) protocol. The patient rapidly improved symptomatically with IVF (intravenous fluids). 

The patient was clinically stable and did not have findings of severe alcohol withdrawal. The patient did not have symptoms that required an acute inpatient level of care, and he had not failed management in a lesser level of care. 

Medically necessary services are typically those which are safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment options. 

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this scenario.