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

Diagnosis: Cancer in mouth
Treatment: CT scan

The insurer denied the CT scan. The denial is overturned. 

Yes, the CT scan is medically necessary. 

The patient is a female with a history of adenoid cystic carcinoma that was resected. She also received radiation treatment. She has been seen yearly for follow-up treatment that included a CT of the head and lungs. The recent request for the CT's has been denied based on the plan guidelines that states that CTs after six-months of treatment completion are only authorized if there are new symptoms. 

Adenoid cystic carcinoma (ACC) is an aggressive salivary gland neoplasm characterized by high rates of local recurrence, early metastasis, and a poor long-term prognosis. Approximately 20-50% of cases result in distant metastasis, commonly involving the lung, bone, liver, and brain. There is no association between recurrence, and age or histopathological types. Recurrences are observed after many years from the initial diagnosis. There may be no findings on clinical examination. For this reason, patients are kept under long term follow-up. From the literature, follow-up for patients with adenoid cystic carcinoma ranges from 4-14 years. Maxillofacial surgeons need to maintain a high index of suspicion for recurrence as adenoid cystic carcinoma may recur outside the standard follow-up window. Long-term follow up of patients with salivary gland neoplasms is mandatory because of the frequently indolent but relentlessly infiltrative behavior associated with late recurrence and distant metastasis of adenoid cystic carcinoma. Adenoid cystic carcinoma is a unique malignant salivary gland tumor associated with prolonged survival even in metastatic settings, which emphasizes the necessity for lifetime follow-up. Late relapses (>five years postoperatively) are well documented as are reports of rapid tumor progression after an extended period of indolent disease. 

Follow-up with CT's is indicated due to the long term chance of recurrence. The six-month time limit in the plan language is not compatible with the literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Dental Disorder
Treatment Braces.  The insurer denied braces.
The determination is upheld.

The patient has a Skeletal Class I occlusion, severe maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The issue for review is the medical necessity for braces.

The braces are not medically necessary. The research supports that in many cases of mixed dentition, medical necessity is based on the orthodontic screening and professional judgement of the dentist. Although some orthodontic intervention may be beneficial in the long term, there is no strong evidence showing medical necessity in some cases.  Medically necessary cases in the mixed dentition usually present with severe anterior crossbite, deep impinging overbite, or severe crossbite in combination with other malocclusion factors. 
Since this patient is in middle mixed dentition with 11 primary teeth, the case does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental disorder
Treatment: Braces.  The insurer denied braces.
The determination is upheld.

This is a patient with a skeletal Class I, Class II cuspid malocclusion, moderate maxillary crowding and mild mandibular crowding, moderate overjet and severe overbite. At issue is the medical necessity for braces.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 22 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 mm or greater and underbite 3.5 millimeters (mm) 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 are not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Head and neck pain
Treatment: Procedure codes 64590, 64575, 76000, 95972, 64555
(Electrical nerve treatment [occipital nerve stimulation])
The insurer denied the Procedure codes 64590, 64575, 76000, 95972, 64555
(Electrical nerve treatment [occipital nerve stimulation])
The denial is overturned. 

The patient is a female with recalcitrant occipital neuralgia. She has severe pain and has failed conservative and surgical treatment. 

Yes, the health plan should cover the proposed treatment with electrical nerve treatment, occipital nerve stimulation.

Yes, the requested health service is likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.

The patient is a female with severe occipital neuralgia. Occipital nerve stimulation for refractory occipital neuralgia is an emerging technique with new and positive studies showing its success. The patient is refractory to all other treatment. She has failed injections, surgery, opiate medications. The options are limited. The patient is on Methadone. Increasing chronic opiates is not without risk and given the patient's age and presence of neuropathic pain, unlikely to be effective in the long run. The patient has had an occipital nerve decompression. Thus, leaving occipital nerve stimulation as the final option. Numerous studies have shown this technique to be safe, and effective. In addition, the procedure is reversible. A recent prospective long-term trial showed greater than a drop of four points on the visual analog scale (VAS) and essentially no complications in a trial for intractable occipital neuralgia at up to seven years follow up. These results are improved upon previous trials. Given the above, the requested occipital stimulation is medically appropriate and should be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Head and neck pain
Treatment: Procedure codes 64590, 64575, 76000, 95972, 64555
(Electrical nerve treatment [occipital nerve stimulation])
The insurer denied the Procedure codes 64590, 64575, 76000, 95972, 64555
(Electrical nerve treatment [occipital nerve stimulation])
The denial is overturned. 

The patient is a female with history of neck pain and headache. She has failed medical medications including non-steroidal anti-inflammatory drugs (NSAIDs), meloxicam, and steroids as well as opioids. Exam reveals no focal deficit. After occipital nerve block on the right, the pain levels decreased by 50%. The patient was recommended for occipital nerve stimulation trial followed by permanent implantation if a successful trial. The patient has undergone occipital neurolysis in the past without improvement. 

Yes, the health plan should cover the proposed treatment with electrical nerve treatment, occipital nerve stimulation.

Yes, the requested health service is likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.

The proposed treatment is considered medically appropriate and within the standard of care. The patient has undergone best medical management including injections and pain medications without improvement. The patient has undergone previous surgical intervention including neurolysis and in the setting of failure of neurolysis, the only option for possible benefit is occipital nerve stimulation. The patient did have a positive response with the injections with 50% reduction in the pain levels and therefore she would be considered a candidate based upon standard of care.

The literature does support this surgery and so the denial should be overturned. This is considered medically appropriate and within the standard of care and therefore should be approved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental health/Attention deficit hyperactivity disorder (ADHD)
Treatment: Pharmacy prescription drugs. 
The insurer denied Vyvanse 40 mg 2 tablets (60 tablets a month). 
The denial is overturned in whole. 

This case involves a patient diagnosed with attention deficit hyperactivity disorder (ADHD) with a co-morbid diagnosis of bulimia (binge eating). The patient has demonstrated a response to Vyvanse 80 milligrams (mg) daily with noted benefit from this medication.

Yes, the requested health service/treatment of Vyvanse 40 mg (lisdexamfetamine) with quantities of 60 pills at 40 mg is medically necessary for this patient.

The requested benefit of Vyvanse at a daily dose of 80 mg with two 40 mg caps per day is medically necessary for this patient and clinically appropriate with regard to the indications for use. Vyvanse is being prescribed by a mental health practitioner. Additionally, psychological testing affirmed the diagnosis of ADHD. The Vyvanse is prescribed for a patient who benefits with regard to improved symptoms and functioning, and who has been effectively treated at the current dose of 80 mg daily for over 4 years. The dose of medication is individualized and was titrated as clinically appropriate. Treatment with a lower dose would be detrimental to the patient with a reasonable degree of medical certainty.

The requested Vyvanse is backed by scientific evidence that means the results of controlled clinical trials or other studies are published in peer-reviewed, medical literature; the requested medication for the diagnosis of attention deficit hyperactivity disorder is generally recognized by the relevant medical specialty community; and is consistent with prevailing medical standards and clinical guidelines including national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines, as referenced below. Vyvanse at a daily dosage of 80 mg daily for the treatment of attention deficit hyperactivity disorder (ADHD) is reasonable, in the patient's best interest, and consistent with prevailing standards of medical practice, as well as the Food and Drug Administration (FDA) indicated use for the treatment of ADHD at a dose that has been prescribed for over 4 years with coverage from other health plans.

Specifically, in this case, the patient has demonstrated a clinical response to the requested treatment with Vyvanse 80 mg daily (two 40 mg pills); thus, it is in the patient's best interest to remain on this medication that provides clear therapeutic benefit, especially with respect to daily functioning. The requested benefit with Vyvanse 80 mg daily is provided for the purpose of treating ADHD, as clinically appropriate and indicated; and is entirely consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibrillary glomerulonephritis (FGN). 

Treatment: Positron emission tomography (PET) and computed tomography (CT) of the whole body. 

The insurer denied coverage for positron emission tomography (PET) and computed tomography (CT) of the whole body. 

The denial is upheld. 

This female patient is diagnosed with fibrillary glomerulonephritis (FGN) and her nephrologist is concerned about underlying malignancy, the patient refused magnetic resonance imaging (MRI) with contrast due to concerns regarding nephrogenic systemic fibrosis and she is a poor candidate for computed tomography (CT) with contrast due to decreased glomerular filtration rate (GFR). Her nephrologist has requested positron emission tomography (PET) scan to rule out malignancy due to known history of lymphadenopathy. 

As discussed in Up to Date, most cases of fibrillary glomerulonephritis were previously considered idiopathic. However, 30 to 50 percent of cases of fibrillary glomerulonephritis are associated with malignancy, monoclonal gammopathy, autoimmune disease, or infections. The frequency with which these associated disorders occur was illustrated in a report of 66 patients with fibrillary glomerulonephritis. Fifteen patients (23 percent) had an associated malignancy, which was diagnosed 15 years before to 10 years after the onset of renal disease.  Six of the 15 malignancies were due to multiple myeloma or leukemia. Eleven patients (17 percent) had a monoclonal gammopathy, which is similar to the 15 percent incidence reported in another study. 10 patients (15 percent) had autoimmune disorders (most often Crohn disease, lupus, Graves' disease, and immune thrombocytopenia (ITP). 

Ferrer, et al. states, "Imaging tests for the evaluation of lymphadenopathy are helpful if it is not clear after physical examination that there is lymphadenopathy and/or to evaluate surrounding structures for abnormalities. Imaging by computed tomography (CT), ultrasound, Doppler technology, or magnetic resonance imaging (MRI) can help distinguish enlarged lymph nodes from other structures and define the pathologic process, especially cystic changes. Imaging can provide clues to diagnosis but usually cannot replace biopsy and PET CT is not used as initial study." 

In addition, no laboratory testing was done to differentiate between malignant versus infectious etiologies for lymphadenopathy. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Positron emission tomography (PET) and computed tomography (CT) of the whole body is not considered medically necessary for this patient. 

The carrier's denial of coverage for Positron emission tomography (PET) and computed tomography (CT) of the whole body is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvis Mass
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.

This is a female patient with a diagnosis of a pelvic mass who underwent an uncomplicated robotically assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy and uterosacral ligament suspension. The procedure was performed under general anesthesia without complications. The patient was able to urinate, ambulate and tolerate oral intake. After a period of medical stability she was discharged home with follow up instructions. 

There are many ways of doing a hysterectomy.  The trend has been towards less invasive procedures.  Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic supracervical hysterectomies are outpatient procedures unless a complication arises.  Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to the Milliman Care Guidelines, Inpatient and Surgical Care 23 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure.  Inpatient stay may be needed for: surgical complications (bladder ureter or bowel injury or hemorrhage); conversion to abdominal hysterectomy; complex surgery (staging of endometrial cancer); wound complications; comorbidities. In this case, this patient did not have any of these criteria.  The patient's procedure was uncomplicated, and she had minimal blood loss from the procedure.  The procedure was for a benign fibroid.  There was no evidence of any injury to this patient's other organs.  Post operatively, the patient was stable.  Nothing in the submitted clinical information suggested any serious problem that warranted inpatient admission for this patient.  

As per medical literature, laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. This patient could have been safely monitored with overnight stay if required without inpatient admission. 

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 stay should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hyperkalemia.
Treatment:  Inpatient Hospital.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a history of end stage renal disease (ESRD) on dialysis and liver cirrhosis.  He presented to the hospital with chest pain and shortness of breath.  The last dialysis session was shortened to 45 minutes.  The day of presentation he had an argument with the dialysis team and did not get a dialysis treatment.  The patient denied sudden onset chest pain, palpitations, fevers, cough, leg swelling or syncope.  On exam, he was afebrile with a blood pressure of 154/88, a pulse of 88, a respiratory rate of 19 and a pulse oximetry of 100%.  On exam, he was well appearing in no acute distress and without increased work of breathing. Lab results showed a potassium of 5.7, white blood cell count (WBC) of 3.23, a hemoglobin of 10.3, a carbon dioxide (CO2) of 27, a creatinine of 6.44, and a blood urea nitrogen (BUN) of 25.  A chest x-ray did not show acute edema, consolidation or infiltrates. An electrocardiogram (EKG) did not show acute changes.  He was given albuterol and kayexylate and was admitted to medicine for dialysis.  He was seen by nephrology and underwent dialysis for 3.5 hours.  The patient was stable for discharge.  At issue is the medical necessity of an inpatient admission.

The inpatient stay was not medically necessary based on the documentation provided.  The patient presented with chest pain and  baseline shortness of breath after not receiving dialysis.  He was not in any acute distress and was hemodynamically stable.  He did not have uremic pericarditis, uremic encephalopathy or uremic bleeding.  He did not have respiratory distress.  He did not have clinically significant cardiac arrhythmias.  He did not have severe electrolyte of metabolic abnormalities.  He had a potassium of 5.7 but did not have any EKG changes or arrhythmias.  He did not have severe or persistent nausea or vomiting.  There was no other documented reason for an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Viral Myositis, Influenza A

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was overturned. 


This is a male patient who presented to the hospital with bilateral leg pain and difficulty walking. The patient was positive for influenza, and was found to have elevated creatinine kinase of 4,267. The patient's clinical presentation was consistent with rhabdomyolysis and he was admitted for pain control. His hospital medical management included intravenous (IV) fluid bolus, strict intake and output and contact precaution. After a period of medical stability he was discharged home with outpatient follow up instructions.

According to Chen, et al. (2013), the clinical management of rhabdomyolysis includes prompt and aggressive fluid resuscitation, prevention of progressing to acute kidney injury, early correction of potentially lethal electrolyte disturbance, correction of severe metabolic acidosis, and managements of other coexisting complications. As per Torres et al (2015), "Treatment for rhabdomyolysis, at least initially, is mainly supportive, centering on the management of the ABCs (airway, breathing, circulation) and measures to preserve renal function, including vigorous rehydration." 

Nance et al (2015) informs, "The characteristic clinical features of rhabdomyolysis include myalgia, muscle weakness, and muscle swelling which develop over hours to days4, 5. In a case series of 37 pediatric patients with elevated creatine kinase (CK) 1000 U/L, the most common presenting symptoms were muscle pain (84%), weakness (73%) and muscle swelling (8.1%) 6. And as per Alaygut et al (2017), "Several causes of infection may be associated with rhabdomyolysis. Viral infections are responsible for one third of the cases [5,10] (Many infections are associated with rhabdomyolysis. While influenza takes place on the top among viral infection agents, Epstein-Barr virus (EBV), cytomegalovirus (CMV), and human immunodeficiency virus (HIV) are the other causes [4]." 

Literature supports that rhabdomyolysis is a potentially life-threatening syndrome that can develop from a variety of causes, including viral myositis as seen in this patient. Infection is the major cause of rhabdomyolysis in children younger than 10 years and can lead to acute kidney injury if it is not managed properly. Thus, inpatient admission was medically necessary for this patient to prevent acute kidney injury. The patient presented with evidence of rhabdomyolysis (i.e., muscle pain and difficulty walking secondary to viral myositis). The patient was admitted for aggressive hydration which he would have been unable to tolerate orally. 

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

Based on the above, the medical necessity for inpatient admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic cystocele

Treatment: Inpatient stay

The insurer denied coverage for the inpatient stay.

The denial is upheld.

This is a female patient with a diagnosis of a symptomatic cystocele who underwent a vaginal hysterectomy, left oophorectomy, and anterior colporrhaphy. The procedure was reported as uncomplicated; the estimated blood loss was 500 cc. Post-operatively, the patient was stable and comfortable. The patient was admitted after surgery and was discharged on day 3 of admission.

A vaginal hysterectomy is an outpatient procedure. The safety of this approach has been documented in multiple studies. Admission is usually not necessary unless there is a possible complication, such as heavy bleeding, surgical complications (bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, wound complications, or comorbidities. In this case, this patient's procedure was uncomplicated, and there was no evidence of any injury to other organs. A vaginal hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. In other words, the patient could have been monitored overnight without the need for a full inpatient admission. Once the provider ascertained that the patient was stable, the patient could have been discharged to home. Based on the review of the medical record and literature, the inpatient admission was not medically necessary for this patient's care and management.

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

Based on the above, the medical necessity for the inpatient stay is not substantiated.  The insurer's denial should be upheld.