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

Diagnosis: Morbid Obesity. 
Treatment: Intragastric Balloon. 

The insurer denied coverage for intragastric balloon. 

The denial is overturned. 

Intragastric balloons are placed endoscopically to aid in weight loss. The efficacy of the balloon is in the behavioral effect (i.e. changes in diet and lifestyle) and the effect of the balloon itself. Manufacturer recommendations indicate that standard treatment is for six months. Contraindications for the intragastric balloon include previous gastric surgery, a hiatal hernia greater than or equal to 5 centimeters (cm), coagulation disorders, bleeding lesions of the upper gastrointestinal tract, pregnancy or the desire to become pregnant, breastfeeding, alcoholism, drug addiction, severe liver disease, or contraindications to endoscopy. Relative contraindications include previous abdominal surgery, hiatal hernia, esophagitis, Crohn's disease, nonsteroidal anti-inflammatory drug (NSAID) use, or uncontrolled psychiatric disorders. Studies have demonstrated significant improved weight loss in patients undergoing balloon placement versus diet and exercise alone. 

Per clinical documentation, this is a female patient with a history of gastroesophageal reflux disease (GERD) and obesity. Her BMI (body mass index) is 39.9. The patient had an esophagogastroduodenoscopy (EGD) that demonstrated "mild chronic nonspecific carditis." The medical records provided do not indicate any contraindications to the placement of the intragastric balloon. Per the provided clinical documentation and societal guidelines, the intragastric balloon would be medically necessary for a period of 6 months. Based on the above, an intragastric balloon is medically necessary. 

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

The insurer's denial of coverage for an intragastric balloon is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures. 
Treatment: Inpatient Hospital Stay. 

The insurer denied coverage for an inpatient hospital stay. 
The denial is upheld. 

The patient has a past medical history of complex posttraumatic stress disorder, epilepsy, status post vagal nerve stimulation, asthma, eating disorder, benign essential tremor, osteopenia, migraine headaches, esophageal tear, and obesity. The patient presented to the emergency department with a chief complaint of seizures. A few days ago, she had 3 seizures within 1 hour after having over 5 years of seizure freedom. The following day the patient's Klonopin was increased. The next day she had a 2.5-minute unresponsive seizure followed by "30 minutes post ictal shaking, slurring, and stuttering." The patient went to another hospital where her Topamax was doubled. She was given a loading dose of Keppra and Ativan. She apparently had a seizure while admitted and continued to have approximately 3 per day. Her last one was the morning of presentation. The patient was concerned that the vagal nerve stimulator might not be working. The physical examination was normal. The patient was admitted for continuous video electroencephalogram (EEG) monitoring for the purpose of evaluation of paroxysmal events, continuation of Topamax, and seizure/fall precautions. Five days later the patient was discharged in stable condition. 

The patient's medical condition and neurological examination was stable at the time of admission. Continuous video EEG monitoring for the purpose of evaluation of paroxysmal events could have been performed at an observation level of care. 

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

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

Diagnosis: Severe Alopecia Areata

Treatment Xeljanz 10 mg (milligrams)

The insurer denied coverage for Xeljanz 10 mg (milligrams)

The denial is overturned 

The patient is a has a diagnosis of severe alopecia areata affecting >50% (percent) scalp.  The patient's past medical history is also significant for multiple autoimmune disorders. Including vitiligo and rheumatoid arthritis.  The patient has failed therapy with topical, intralesional, and oral steroids.  The dermatologist is requesting Xeljanz given the failure of the above therapies and considering her other autoimmune conditions.  

The patient's alopecia areata is unlikely to react with great success to topical therapies and is thus severe enough to warrant systemic therapy.  Given the co-existing conditions, rheumatoid arthritis, and vitiligo, which may also benefit from Xeljanz therapy it is within the standard of care to allow for the use of Xeljanz for the treatment of this patient's alopecia areata.  As a result, the use of xeljanz is medically necessary for use in the treatment of the patient's condition. 

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 Xeljanz 10 mg is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes mellitus, dementia.

Treatment: Increase in Personal Care Services from 8 hours per day, 6 days a week for 48 hours to 12 hours per day, 7 days a week for a total of 84 hours.

The insurer denied coverage for requested increase in Personal Care Services from 8 hours per day, 6 days a week for 48 hours to 12 hours per day, 7 days a week for a total of 84 hours.

The denial is overturned.

This is a patient with multiple medical problems, including hypertension, diabetes mellitus, dementia as well as hearing and vision deficits.  He lives alone.  Under review is the medical necessity of requested increase in Personal Care Services from 8 hours per day, 6 days a week for 48 hours to 12 hours per day, 7 days a week for a total of 84 hours.

The combination of the patient's multiple medical problems and his recent documented functional decline after hospitalization due to hypoglycemia support the medical necessity of the requested increase in Personal Care Services from 8 hours per day, 6 days a week for 48 hours to 12 hours per day, 7 days a week for a total of 84 hours.  The Helps assessment form documents a significant decline in functional status. The patient requires limited to extensive assistance for personal hygiene, upper/lower extremity dressing, locomotion, transfers, and toileting.  He continues to require extensive to maximum assistance with shopping, meal preparation and transportation.     

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

From a physical medicine and rehabilitation perspective, the requested increase in Personal Care Services (PCS) from 8 hours per day, 6 days a week for 48 hours to 12 hours per day, 7 days a week for a total of 84 hours is medically necessary.

The insurer's denial of coverage for an increase in Personal Care Services from 8 hours per day, 6 days a week for 48 hours to 12 hours per day, 7 days a week for a total of 84 hours is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Endocrine
Growth Hormone

Diagnosis: Short stature
Treatment; Growth hormone
The insurer denied Nutropin AQ. The health plan's determination is upheld. 

The patient is a female who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). Her past medical history is significant for motor and speech delay. Her mother is 68 inches tall and father is 69 inches. She was diagnosed with attention deficit hyperactivity disorder (ADHD) and had started on stimulant since then.
She was initially evaluated by pediatric gastroenterology for poor weight gain and her evaluation was unremarkable.

Nutropin AQ is not medically necessary for this patient.
Stimulant induced growth failure is a well known phenomenon and suboptimal nutrition seems to be the likely etiology of stimulant induced growth failure. Clearly, this patient does not qualify for GH treatment under ISS indication.
In 2003, the US Food and Drug Administration (FDA) approved injectable somatropin (Humatrope) for the treatment of idiopathic short stature, also called non-GH-deficient short stature, defined by height standard deviation score (SDS) <=-2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients for whom diagnostic evaluation excludes other causes of short stature that should be observed or treated by other means.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Family history of breast cancer. 
Treatment: Magnetic Resonance Imaging (CPT 77049) Without Contrast (dye). 

The insurer denied the Magnetic Resonance Imaging (CPT 77049) Without
Contrast (dye). 
The denial is overturned. 

The patient is a female. She has reported family history of breast cancer. She has a
risk of breast cancer over 20% by Tyrer-Cuzick score. Her cousin had breast
cancer. She also has a breast mass and nipple discharge, although these are
reported to be present for over several years. 

Yes, the requested magnetic resonance imaging is medically necessary. 
With a lifetime risk of breast cancer of 20%, this individual would meet accepted
criteria for breast cancer screening with MRI (magnetic resonance imaging) in
addition to standard mammography. 

As the patient's cousin was close in age when diagnosed with breast cancer, she
would be eligible to start screening 10 years prior to the age of diagnosis of the
proband, and therefore MRI (magnetic resonance imaging would be appropriate. 
No, the health plan did not act reasonably, with sound medical judgment, and in the
best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Family history of breast cancer
Treatment: Magnetic Resonance Imaging (CPT 77049) Without Contrast (dye)
The insurer denied the Magnetic Resonance Imaging (CPT 77049) Without
Contrast (dye)
The denial is overturned

The patient is a female. She has reported family history of breast cancer. She has a
risk of breast cancer over 20% by Tyrer-Cuzick score. Her cousin had breast
cancer. She also has a breast mass and nipple discharge, although these are
reported to be present for over several years.

Yes, the requested magnetic resonance imaging is medically necessary.
With a lifetime risk of breast cancer of 20%, this individual would meet accepted
criteria for breast cancer screening with MRI (magnetic resonance imaging) in
addition to standard mammography.

As the patient's cousin was close in age when diagnosed with breast cancer, she
would be eligible to start screening 10 years prior to the age of diagnosis of the
proband, and therefore MRI (magnetic resonance imaging would be appropriate.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Family history of breast cancer
Treatment: Magnetic Resonance Imaging (CPT 77049) Without Contrast (dye)
The insurer denied the Magnetic Resonance Imaging (CPT 77049) Without Contrast (dye)
The denial is overturned

The patient is a female. She has reported family history of breast cancer. She has a risk of breast cancer over 20% by Tyrer-Cuzick score. Her cousin had breast cancer. She also has a breast mass and nipple discharge, although these are reported to be present for over several years.

Yes, the requested magnetic resonance imaging is medically necessary.
With a lifetime risk of breast cancer of 20%, this individual would meet accepted criteria for breast cancer screening with MRI (magnetic resonance imaging) in addition to standard mammography.

As the patient's cousin was close in age when diagnosed with breast cancer, she would be eligible to start screening 10 years prior to the age of diagnosis of the proband, and therefore MRI (magnetic resonance imaging would be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle pain
Treatment: Inpatient admission

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

The patient is a male who was admitted to the hospital for ankle pain.  He presented with posterior ankle and calf pain.  He was admitted after his physical examination found a visible defect in his Achilles tendon with ecchymosis and tenderness.  He had a normal white blood cell count.  His magnetic resonance image (MRI) showed a full-thickness rupture of the Achilles tendon.  He received intravenous fluids and prophylactic antibiotics and underwent repair of the Achilles tendon.

No, the proposed inpatient admission was not medically necessary.
The hospital admission for ruptured Achilles tendon was not medically necessary as there were no underlying medical conditions that would have necessitated admission such as a positive ultrasound for deep vein thrombosis (DVT), in which case the patient would be admitted for observation and anticoagulant therapy.  A young healthy patient who suffers an Achilles tendon rupture is typically treated with non-weightbearing and splintage with pain control followed by either nonoperative treatment with immobilization or operative intervention.  Hospital admission is typically not part of the standard of care of a ruptured Achilles tendon.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I malocclusion. 
Treatment: D8080 braces and D8670 monthly visit. 

The insurer denied coverage for D8080 braces and D8670 monthly visit. 

The denial is upheld. 

This is a female with a class I malocclusion. The patient has mild maxillary and moderate mandibular crowding with an overjet of 3 millimeters and an overbite of 4 millimeters. Orthodontic treatment recommended has been denied as the handicapping labio-lingual deviation (HLD) score is 12. 

The insurer's dental director states that the HLD is 12. The provider states that the patient automatically qualifies as there is a deep bite. To qualify with a deep bite, there must be documentation that the lower incisors are destroying the soft tissue of the palate. The photographs do not show that there is damage to the palatal tissues. The criteria for a deep bite are not met. This reviewer agrees with the dental director that the overjet is 3 millimeters, overbite is 4 millimeters, there is one ectopic eruption, and the labiolingual spread is 2 millimeters. Therefore, as the HLD is below 26, the guidelines for braces and monthly visits are not met. 

The HLD score is below 26 and the patient does not have a handicapping malocclusion. The treatment is not considered medically necessary. 

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

The insurer's denial of coverage for the D8080 braces and D8670 monthly visit is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission

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

The patient is a female. She presented to emergency room with shortness of breath. The patient has a smoking history, but no history of COPD (chronic obstructive pulmonary disease) or asthma. The patient failed outpatient treatment with Z-pak and ventolin. The patient was admitted to acute in hospital level of care for further management.

The acute inpatient admission was denied by the health plan due to lack of medical necessity. This denial is being appealed.

No, the inpatient admission was not medically necessary.
The patient, who had dyspnea and who had failed outpatient therapy, responded well with ER (emergency room) treatment. Within 24 hours, the patient was hemodynamically stable. The oxygen levels were above 90% on room air. The patient was tolerating oral diet and was capable of ambulation. Thus, the acute inpatient level of care is not medically necessary. The patient could have been safely and effectively treated at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System /Gastrointestinal. 
Treatment: Skilled Nursing. 
The insurer denied acute rehab facility stay. 
The determination is upheld.

The patient is a male with medical history significant for hypertension, peptic ulcer disease, hepatitis B and Huntington's Chorea who was admitted to an acute care hospital where he was diagnosed and treated for an upper gastrointestinal (GI) bleed. The subject under review is the medical necessity for acute rehabilitation facility stay.

The health plan's determination is upheld in whole.

The requested Acute Rehab facility stay is not medically necessary for this patient. Review of documentation did not support need for close medical supervision by a physician. Additionally the rehab history and physical (H&P) noted that the patient was ambulating 80 feet x 2 with contact guard assist (CGA). Also noted the patient was completing both upper body dressing (UBD) and lower body dressing (LBD) with minimal assistance (MINA) and, per Speech Language Pathologist (SLP) evaluation, was tolerating a regular diet with thin liquids and cleared for regular soft diet and thin liquids.  Therapy then noted that the patient had already progressed to supervision for sit to stand transfer and lower body dressing. This functional level is appropriate for a lower level of care to meet the patient's goal of achieving prior level of function of independence.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient. 
Insurer denied nursing home service; admission type long term care. 
The denial is upheld.

The patient is a male with past medical history significant for hypertension, hyperlipidemia, atrial fibrillation, diabetes, and foot ulcer. The patient was diagnosed and treated for osteomyelitis of the right foot. He was transferred to a Skilled Nursing Facility (SNF). 
Request was for nursing home service; admission type long term care and the denial was upheld. The Plan stated that the patient was "able to dress yourself and to feed yourself...o to the bathroom without help...our needs can be met in the community setting."
The subject under review is the medical necessity for Nursing Home Service; Admission Type Long term care (LTC) for this patient.

The health plan's determination is upheld.

Nursing home service; admission type long term care, was not appropriate nor medically necessary for this patient. The documentation noted that the patient had a medically necessary SNF stay. Records do not support long term care after discharge from SNF.
The patient is a male with multiple medical problems, but documentation supports that he was at an appropriate level to discharge to the community. For example, despite the patient having COVID19 he was asymptomatic, and was supervision to contact guard assist for self-care. Additionally, it was noted that he was ambulating 225 feet at set up level and negotiating 15 steps with stand by assist (SBA). Ambulation distance was decreased to 40 feet but noted to be completed in room and level of assist was set-up. The patient was ambulating 225 feet setup and greater than 15 steps SBA.
Additionally the physician assistant (PA) noted the patient to be asymptomatic with stable vital signs. It was noted that patient was status/post (s/p) intravenous (IV) antibody infusion, but this is not a reason to keep him in custodial care. Also vital signs were noted as normal and nursing reported no respiratory distress with stable vitals and  the PA stated that the patient was without symptoms, on room air, "Labs, chest x-ray stable. No need of repeat." Similar report was noted on subsequent dates. The PA noted that the patient had received IV antibody infusion (unclear date) with chest x-ray and labs stable and no new concerns. Additionally, the respiratory therapist saw the patient and noted he was on room air; breath sounds clear and continue to monitor. Therefore, the requested care level was not medically appropriate or necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain (nausea, vomiting).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This female patient with a history of polysubstance abuse and intractable vomiting presented to the emergency department complaining of one day of multiple episodes of vomiting associated with nausea and epigastric pain.  She was last admitted two years prior for intractable vomiting. 

The patient's vital signs were as follows: temperature = 38.2, pulse = 72, respiratory rate = 20, blood pressure = 175/88, and pulse oxygenation = 100%.  The patient's exam is remarkable for lethargy and epigastric tenderness.  Labs revealed: white blood cells (WBC) = 10/3, hemoglobin/hematocrit (H/H) = 12.6/39/3, platelet (Plt) = 341, sodium (Na) = 140, potassium (K) = 3.7, blood urea nitrogen/creatinine (BUN/Cr) = 13/.61, and glucose = 217.  The patient's chest x-ray showed no acute disease.  Her electrocardiogram (EKG) showed sinus bradycardia, QTc 457.  The patient was admitted.  Treatment included intravenous fluids, intravenous Protonix, Reglan, and Zofran. An abdominal/pelvic computed tomography (CT) was ordered.  The following day the patient's vital signs were stable.  She has pain radiating to back.  The patient eloped from the emergency department.

No, the proposed treatment was not medically necessary.
This patient has a history including intractable abdominal pain and was admitted after presenting with abdominal and vomiting.  The patient was hemodynamically stable and afebrile.  She had normal oxygenation.  She did to have severe electrolyte abnormalities.  She was not dehydrated.  She did not have severe pain.  There is no evidence of inability to tolerate oral intake.  There is no evidence of obstruction or ileum.  This presentation does not support an acute inpatient level of care.  Inpatient Hospital Admission is not medically necessary.

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