Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Neurocardiogenic syncope.
Treatment: Leadless pacemaker
The insurer denied a Leadless pacemaker.
The determination is upheld.

This is a male patient with a history of neurocardiogenic syncope and anxiety. He has had recurrent syncope despite treatment with beta adrenergic blockers. Tilt table testing was remarkable for loss of consciousness and prolonged asystole. At issue is whether a leadless pacemaker is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Leadless cardiac pacing is a relatively new technology. There are two Food and Drug Administration (FDA) approved leadless ventricular pacemakers and a dual chamber device is in clinical trials. The primary advantage of these devices is the elimination of several complications associated with transvenous pacemakers and leads including pocket infections and hematoma and lead fracture. At this time, there are no randomized controlled trials directly comparing outcomes with leadless versus transvenous pacemakers. Data obtained from observational studies have shown similar rates of vascular events and lead dislodgement, markedly fewer infectious complications and more cardiac perforations/pericardial effusions, with leadless versus transvenous devices. Despite the lack of a lead traversing the tricuspid valve with leadless devices, the incidence of tricuspid regurgitation does not seem to be significantly less, possibly due to mechanical interference on the valve or subvalvular apparatus. Long-term data are lacking and the patient population that would most benefit from this technology has yet to be fully defined. In this particular situation, there are no data indicating that a leadless pacemaker would be likely to be more beneficial than a traditional transvenous pacemaker. A conventional device would be expected to produce equivalent results.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Neurocardiogenic syncope.
Treatment: Leadless pacemaker
The insurer denied a Leadless pacemaker.
The determination is upheld.

This is a patient with a history of recurrent neurocardiogenic syncope. His heart was structurally normal. A tilt table test demonstrated loss of consciousness with prolonged asystole. A pacemaker was planned. A leadless type of device is under review, as to whether it is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

A leadless pacemaker has been developed to potentially decrease pocket and lead complications, infections, and malfunctions and those who are susceptible to these complications, such as those at high risk for infection. It may also be considered for those without adequate venous access. In this case, there was no contraindication to placement of a transvenous pacemaker. In this setting, a leadless pacemaker, compared to a transvenous device, has not been established as standard of care towards improved cardiac outcomes. Therefore, it would likely not be more beneficial than standard treatment of a transvenous pacemaker.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, cough, chest pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient is a female with a history of asthma, breast cancer on chemotherapy, and hypertension. Her presenting complaints were dyspnea present for one month, a cough, and chest pain. The physical exam was notable for wheezing. Lab results were notable for venous blood gas (VBG) potential hydrogen (pH) 7.36, partial pressure of carbon dioxide (pCO2) 52.8, and white blood cell count (WBC) 18. Radiology was notable for a chest x-ray without evidence of pneumonia. The patient was admitted to an inpatient level of care for treatment of an asthma exacerbation. At issue is the medical necessity of an inpatient hospital stay.
The inpatient hospital admission is not medically necessary.
The patient presented with dyspnea and cough present for one month with signs and symptoms consistent with a mild asthma exacerbation evidenced by mild hypercapnia (some element of which is likely chronic) and wheezing. The patient did not have respiratory distress, severe symptoms, or hypoxia. A lower level of care would have been reasonable to monitor the patient for progression of symptoms and response to treatment.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: infertility.
Treatment: In Vitro Fertilization (IVF) Cycle. 
The insurer denied In Vitro Fertilization (IVF) Cycle.
The health plan's determination is upheld. 

The patient is a woman seeking pregnancy. She and her partner are carriers for Tay-Sachs. They have 3 chromosomally normal, non-affected embryos. At issue is the medical necessity of another in vitro fertilization (IVF) cycle.

In Vitro Fertilization (IVF) Cycle is not medically necessary for this patient.
Another IVF cycle is not currently medically necessary to treat this patient's condition. She and her partner have 3 chromosomally normal, non-affected embryos. Each of those embryos has an over 50% chance of yielding a baby that does not have Tay-Sachs. These are reasonable chances and should likely yield at least 1 live birth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history significant for hyperlipidemia, hypertension, active smoking, coronary artery disease (CAD) status/post (s/p) myocardial infarction (MI), and polysubstance abuse who presented to the emergency department (ED) for evaluation of chest pain and shortness of breath. An electrocardiogram (ECG) demonstrated normal sinus rhythm without ischemic changes. A chest x-ray (CXR) demonstrated pulmonary vascular congestion. The high sensitivity (HS) cardiac troponin was high, 95 nanograms per liter (ng/L) but remained flat. The patient was admitted to the telemetry service under an inpatient level of care for evaluation and treatment of possible acute coronary syndrome (ACS). The patient's symptoms improved, and he was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
An inpatient level of care was not medically necessary for evaluation and management of this patient presenting with chest pain.
The patient presented with chest pain and shortness of breath in the setting of noncompliance with taking his home medical therapy. The HS cardiac troponin was elevated but remained flat, consistent with a chronic myocardial injury, not acute coronary syndrome (ACS). The patient's symptoms were deemed likely non-cardiac in etiology. Echocardiogram findings were stable showing a normal left ventricular ejection fraction (LVEF) with normal wall motion. The patient had undergone left heart catheterization (LHC) in the past demonstrating mild non-obstructive CAD. No further inpatient cardiac workup was recommended. Given the patient's symptoms and cardiac troponin elevation were not consistent with ACS, an inpatient level of care was not medically necessary in this case supported by the 2014 American Heart Association (AHA) /American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes and the 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department (1, 2).
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Seizure Disorder
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is partially overturned.

This is a male child with a complex medical history significant for hypoxic ischemic encephalopathy, spastic quadriplegic cerebral palsy, epilepsy, gastrostomy tube dependence, and scoliosis who presented to the emergency department (ED) with a seizure after a choking episode while at his pediatrician's office. The seizure lasted 40-50 seconds with stiffening extremities and eyes rolled back. He had been having choking episodes over the prior several weeks, had been seen in the ED a week prior for a similar episode, and had months-long history of abnormal breathing. The examination was significant for sleeping but arousable, no acute distress, moist mucous membranes, tachypnea, crackles at the left lung base, mild belly breathing, no nasal flaring, saturations fluctuating 91-93 percent (%), benign abdomen, hypertonia of extremities, contractures of extremities, and non-verbal. A chest x-ray revealed only kyphoscoliosis. Blood culture was pending. Rapid viral screen was negative. He was treated with a dose of albuterol and a dose of ceftriaxone and admitted for further management of suspected aspiration pneumonia.
Admission orders included nothing by mouth pending evaluation by speech and language pathology, medications per gastrostomy tube (GT), albuterol as needed, nebulized saline as needed, cough assist as needed, follow-up blood cultures, intravenous (IV) fluids at maintenance, home anticonvulsant medications, occupational therapy (OT) / physical therapy (PT) consultation, and home bowel regimen. Pulmonology was consulted with recommendations for additional airway clearance and an outpatient sleep study. Neurology was consulted with no changes in the medication regimen. 
The majority of the hospital stay was medically necessary and appropriate. Based on the documentation provided, the patient was tolerating his feedings, with stable body temperature for three days, tolerating enteral antibiotics, with no choking episodes. At this point, he was stable for discharge home. The discharge was held pending delivery of the chest vest because pulmonology had increased his airway clearance regimen to include the vest. He could have been safely discharged home  pending delivery of the vest the following day. It was possible to perform manual chest physiotherapy for airway clearance in the interim.
The final day of the hospital stay was not medically necessary. He could have been safely discharged the prior day.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis
Treatment: Qalxdy (tofersen)
The insurer denied: Qalxdy (tofersen)
The denial is overturned.

The patient is an adult male with history of amyotrophic lateral sclerosis with SOD1 (superoxide dismutase type 1) mutation. He has been on Qalsody (tofersen). Qalsody is FDA (Food Drug Administration) approved to treat amyotrophic lateral sclerosis in adults with SOD1 (superoxide dismutase type 1) mutation. He has been on the medication for two years without clinical progression. The patient's attending physician is requesting for authorization to continue the medication. 

The health plan should cover the proposed treatment. 

The patient is an adult male with history of amyotrophic lateral sclerosis with SOD1 (superoxide dismutase type 1) mutation. He has been on Qalsody (tofersen). Qalsody is FDA (Food Drug Administration) approved to treat amyotrophic lateral sclerosis in adults with SOD1 (superoxide dismutase type 1) mutation. He has been on the medication for two years without clinical progression. Qalsody is medically appropriate for this patient - it is not experimental/investigational - it is FDA (Food Drug Administration) approved for this specific disease entity. This is the only treatment that is approved for the patient's condition, it is more beneficial than any standard treatment for the patient's condition or disease. The medical records indicate that the patient's cannot survive without the medication, and that it is now FDA (Food Drug Administration) approved.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis
Treatment: Qalxdy (tofersen)
The insurer denied: Qalxdy (tofersen)
The denial is overturned.

The patient is an adult male with amyotrophic lateral sclerosis. (ALS) with SOD1 (superoxide dismutase type 1) mutation who is currently receiving Qalsody. The Provider wishes to continue Qalsody. The request was previously denied as it was considered experimental/investigative. 

The health plan should cover the proposed treatment. 

Qalsody is FDA (Food Drug Administration) approve for ALS (amyotrophic lateral sclerosis) in those who have SOD1 (superoxide dismutase type 1) mutation like this patient, and therefore cannot be considered experimental/investigative. This was despite the fact that primary endpoints of the clinical trial were not met although the medication reduced serum neurofilament and SOD1 (superoxide dismutase type 1) concentration in CSF (cerebrospinal fluid). Qalsody is the first FDA (Food Drug Administration) treatment for those who have ALS (amyotrophic lateral sclerosis) with the SOD1 (superoxide dismutase type 1) mutation. Furthermore, this is a continuation and discontinuing will cause a more rapid progression.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis
Treatment: Qalxdy (tofersen)
The insurer denied: Qalxdy (tofersen)
The denial is upheld.

The patient is an adult male with amyotrophic lateral sclerosis (ALS) and superoxide dismutase type 1 (SOD1- superoxide dismutase type 1) gene mutation. The provider has requested Qalsody (tofersen). The requested medication was denied coverage as experimental/investigational. 

The health plan should not cover the proposed treatment. 

The requested health service or treatment has not been demonstrated to be more beneficial than any standard treatment for the insured's condition or disease. The clinical trial leading to the US Food and Drug Administration (FDA) approval of Qalxdy 
failed to demonstrate any significant benefit to persons receiving this treatment (1). The FDA (Food and Drug Administration) approval of this drug is based on biomarker data that has not been validated as correlating with beneficial effect in patients (2). As this has not been shown to improve health outcomes, it is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Hospital Admission
The health plan denied the inpatient hospital admission.
The determination is upheld.

The patient is female who was admitted for syncope with nausea and vomiting in addition to headache. The head imaging was normal. An Echocardiogram showed normal ejection fraction. She was treated with intravenous (IV) fluids and remained stable during this hospitalization. 

Per the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, the initial evaluation of syncope includes a careful history and physical examination and an electrocardiogram (ECG). The findings of this initial evaluation can often identify patients who are at low risk for a dangerous etiology (e.g., arrhythmia). Absent other indications for inpatient care, patients with presumptive reflex-mediated syncope (e.g., vasovagal syncope, carotid sinus syndrome, micturition syncope, cough syncope), or syncope due to orthostatic hypotension or dehydration can be managed in the outpatient setting. Patients at intermediate risk for a cardiogenic etiology (arrhythmia, valvular disease) can be further evaluated in an observation care setting, with need for inpatient admission determined by the results of testing and further evaluation (e.g., telemetry)
The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolyte disturbances or change in kidney function. She did not have cardiac arrhythmias and no altered mental status. Therefore, per medical society guidelines, the inpatient admission was not medically necessary and an alternate level of care was more appropriate.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Teeth Spacing Problem
Treatment: Braces 

The health plan denied: Braces 
The determination is: Upheld.

The patient is a female with a Class I occlusion with appropriate overbite and overjet. She has mild maxillary and mandibular spacing. Her treatment is planned for orthodontics to correct her malocclusion.
At issue is the medical necessity of the application of braces.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of braces is not medically necessary for this patient. The patient has some minor spacing. Her overbite is appropriate, and there is no indication of damage to the mandibular incisors in the photographs. Her cephalometric radiograph shows she does not have a traumatic deep bite. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient, therefore, there is no medical reason to correct her malocclusion with braces. While the patient has some space between her teeth, there is no anterior or posterior crossbite detectable on the records provided. There is no evidence of wear or periodontal recession. There are functional problems that may occur in dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] However, this patient presents with none of those conditions. The records provided indicate this patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion[2] If her teeth were aligned it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Physical Therapy
The insurer denied the physical therapy.
The health plan's determination is upheld.

This is a female patient who is diagnosed with back pain. Records provided show the patient was receiving physical therapy (PT) from a participating provider. It was stated that the patient is continuing to benefit from the therapy services provided. There is a PT reevaluation, that was noted to be visit number 9, which indicated the patient had right greater than left low back pain and pain with prolonged sitting, standing, or after inactivity. It was stated the patient had improved from moderate problems sitting to mild problems developing symptoms after more than 60 minutes. Low-back findings indicated bilateral low back pain decreasing, positive sacroiliac (SI) joint test on the left, symptom-free produced a single leg standing on the left leg and on the right. It was noted the patient is independent with a home exercise program. The patient was recommended for an additional 16 visits of PT. It was noted the patient underwent 12 minutes of therapeutic exercise, 12 minutes of self-care/home management training, 12 minutes of manual therapy, and 12 minutes of electrical stimulation.

At issue is the medical necessity for PT.

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

The requested health service/treatment of PT is not medically necessary for this patient.

Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Allow for fading of treatment frequency (from up to 3 or more visits per week to 1 or less), plus active self-directed home PT. Lumbago; Backache, unspecified: 9 visits over 8 weeks." Records provided indicate the patient was diagnosed with low back pain and had completed 9 visits of PT with only mild improvement noted in sitting for more than 60 minutes. It was noted the patient was independent with a home exercise program. There are no exceptional circumstances in this situation that suggest this patient required an extended course of treatment, which appears to have been relying heavily on passive modalities including 12 minutes of manual therapy and 12 minutes of electrical stimulation. It was noted the patient was independent with a home exercise program and had completed the standard of care number of sessions for this condition. Additional PT is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria
Treatment: Bilateral mastectomy, with or without chest reconstruction and with or without pectoralis implants, including nipple/areola reconstruction and tattooing
The insurer denied coverage for bilateral mastectomy, with or without chest reconstruction and with or without pectoralis implants, including nipple/areola reconstruction and tattooing
The denial is overturned

The requested procedure is medically necessary. Moreover, as noted in the letter from the patient's provider, the patient does meet all of the plan's medical policy criteria. The plan has denied coverage because the patient has not been treated with masculinizing hormones unless contraindicated, and the letter confirms that hormones are contraindicated. All other criteria are met as documented in the letter. 

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:

-> Criteria for Breast/Chest Surgery:
    -All patients require documentation of persistent gender dysphoria by a qualified mental health professional. 
-> Criteria for mastectomy and creation of a male chest in female to male (FtM) patients:
    - Persistent, well-documented gender dysphoria;
    - Capacity to make a fully informed decision and to consent for treatment;
    - Age of majority in a given country (if younger, follow the standard of care (SOC) for children and adolescents);
    - If significant medical or mental health concerns are present, they must be reasonably well controlled.
    - Hormone therapy is not a prerequisite.

The patient meets these guidelines. The mental health professional confirms that the patient has well documented persistent gender dysphoria and has the capacity to make an informed decision. The patient is the age of majority. The patient does not have significant mental health concerns. A mental health professional has recommended the mastectomies.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for bilateral mastectomy, with or without chest reconstruction and with or without pectoralis implants, including nipple/areola reconstruction and tattooing is substantiated.