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

Diagnosis: Right hip pain
Treatment: Inpatient hospital admission

The acute inpatient admission was medically necessary.

The patient had severe acute hip and low back pain radiating into an extremity with associated numbness and tingling, difficulty in ambulation, difficulty in weight-bearing with a high risk of fall.  She had a past medical history that raised potentially red flags such as history of breast cancer and history of HIV.  

The need for admission was met because at presentation in the ER, the patient had severe right hip pain and gluteal pain, radiating pain to the right calf with difficulty in weight-bearing and associated high risk of fall, with difficulty in ambulation.  In addition, the patient had a past relevant history of breast cancer s/p chemotherapy and mastectomy, history of HIV, history of bilateral total hip replacement and need for fall precautions. With such history, it was clinically prudent to admit the patient to ensure that she was stable before discharge home.  The option to keep the patient in observation was not appropriate in a clinical presentation when a more extensive diagnostic workup that may take longer than a day was anticipated in view of her medical history of HIV, breast cancer and general debility.

As stated above, the acute inpatient admission was medically necessary.  There was clinical evidence that it would be in whole or in part, reasonably expected to be health beneficial for the patient and/or withholding it in whole or in part would be reasonably expected to affect the patient's health adversely since the patient was in the hospital with history as stated above, making it clinically prudent to admit her to ensure that she was stable before discharge home.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a nasal chrondosarcoma. Treatment has included resection and proton beam radiation. On examination the patient was noted to have a moderate amount of crusting and obstruction in the drainage of the sinuses. CPT code 31237 Nasal/sinus endoscopy surgical; with biopsy, polpectomy or debridement (separate procedure) was denied as not medically necessary because the procedure was done beyond the 30 days from the original surgery. At issue is the medical necessity of the requested procedure.
The health plan's determination is overturned.
The patient's prior surgery (resection of nasal chondrosarcoma) results in recurrent nasal crusting (requiring debridement). Documentation of the patient's clinic visit did show crusting in the nasal cavity that obstructed the paranasal sinuses. The current literature does support the need to remove crusting to improve mucocillary clearance. There is literature to support frequent debridements for sinonasal obstruction. Research by Lee and Byun 2008 supported this and added that patient individualization should be taken into account depending on the extent of surgery and healing progress. As in the case of this patient, the surgeon recognized the need for the crusting removal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma
 
Treatment: DecisionDx-Melanoma Cancer Assay

The insurer denied the DecisionDx-Melanoma Cancer Assay. The denial was upheld.

This is a female patient who is status post right knee biopsy with positive results for melanoma. The pathologic stage was T1a. DecisionDX- Melanoma testing was requested.
Given that these assays are not recommended in clinical guidelines, and the data pertaining to this assay's use is not yet accepted, information gleaned from the assay itself would not materially or appropriately affect the treatment or follow-up approach of most practicing dermatologists.

According to Sondak, V. K., & Messina, J. L. (2016), "The clinical value of this test remains unclear, and the National Comprehensive Cancer Network (NCCN) Guidelines for Melanoma state, "while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low- versus high-risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following sentinel lymph node biopsy [SLNB]) is not recommended outside of a clinical study (trial)." This admonition seems sound, particularly if we apply the same stringent criteria for validation that Mahar et al. applied to clinical prognostic tools that also claim to demonstrate independent prognostic value.  Nevertheless, practicing surgical oncologists are encountering patients with clinically localized invasive melanomas who have already undergone this test at the time of referral.  For the time being, until far more detailed data derived from prospective evaluations are available, there is insufficient evidence to propose that routine clinical management, including decision making regarding SLNB, should be altered by the results of gene expression profiling, although to reassure patients who have already received and are concerned about a "high-risk" determination, more intensive surveillance may be justified." 

Similarly, according to Weiss, S., et al. (2015), "Recently, Castle Biosciences released the DecisionDx-Melanoma gene panel which predicts the risk (high (69%) or low (3%)) of distant metastasis at 5 years for stage I-III patients.  This panel may be used in clinical practice, however it is not currently recommended by any standard treatment guidelines, including the National Comprehensive Cancer Network (NCCN)."

The American Academy of Dermatology melanoma guidelines published in 2019 do not support the use of gene expression profiling.

The carrier's denial of coverage for the DecisionDX-Melanoma Cancer Assay for date of service is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite, crowding
Treatment: Braces
The proposed braces are medically necessary. 

The patient scored a 27 on the handicapping index (threshold for treatment is 26). The patient has his upper canine teeth out of their proper position because of crowding. The patient has a crossbite on the right side. His upper back teeth are inside of his lower teeth and this is "backwards". The crossbite and malposition of the upper canines will cause the patient's teeth to grind together traumatically (not smoothly) as he chews. This will cause, over time, increased wear of his teeth, and possible fracturing. It will also cause increased pressure in his temporomandibular (TM) joints, which could cause degeneration and discomfort in the TMJ. This patient has a definite medical necessity for orthodontic treatment.
Appeal type: Medical necessity
Decision: Overturned

Overbite/Underbite
Dental/Orthodontic Procedure

The patient is a old female with a Class I, crowded occlusion and a deep bite causing soft tissue damage on her palate. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion which was denied based on lack of medical necessity.
The subject under review is the medical necessity of treatment with braces for this patient.

The health plan's determination is overturned.

The requested treatment of braces is medically necessary for this patient.
The patient's orthodontist has documented that the patient is damaging the soft tissue of her palate due to her deep overbite, and her cephalometric radiograph confirms this. Palatal tissue damage is a known side effect of deep bite malocclusions.(1)

A deep bite on its own is not a reason to treat with orthodontics. However, the patient is already damaging the soft tissue of her palate. Studies show deep anterior overbite is associated with periodontal attachment loss.(1) If left untreated this will compromise the bony attachment of the maxillary anterior teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive to correct than the orthodontic problem she currently has.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Bipolar Disorder
 
Treatment:  Inpatient Behavioral Health Admission

The insurer denied the Inpatient Behavioral Health Admission.  The denial was upheld.
 This is a male patient, who was admitted for inpatient mental health treatment.  The patient presented requesting substance rehabilitation treatment; however, it was noted that the patient had more depressive symptoms and anxiety, including despondent moods.  He has had multiple past psychiatric hospitalizations.  He has a history of 3-4 past suicide attempts by overdose, the most recent of which being 3 months prior to this admission.  While hospitalized, it was reported that the patient had no suicidal or homicidal ideations or psychosis and was not an imminent danger to himself or others.  He was discharged to a residential facility.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with aggression, homicidal or suicidal intent, plan, or behavior, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. 

In this case, this patient had reports of depressive and anxiety symptoms, including despondent mood, but no reports of suicidal or homicidal ideation, plan, intent, or behavior.  He had past reported suicide attempts but did not report suicidal thoughts on admission, so there was not enough specific evidence to support that he required only 24-hour acute psychiatric hospital treatment.  The notes reported that he was anxious and despondent but denied suicidal or homicidal ideation, had no reports of hallucinations or delusions, had adequate hygiene, slow activity, and fair impulse control.  He continued to deny suicidal ideation, plan, or intent.  The notes reported that he denied suicidal or homicidal ideation.  There were no reports of manic episodes, aggression, disruptive behavior, self-injurious behavior, paranoid delusions, hallucinations, disorganized speech or thought process, homicidal ideation, plan, or intent, or severe agitation.  There were no reports of acute medical instability or severe withdrawal requiring hospital treatment.  There were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or that could not be achieved in a less restrictive level of care.

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

The patient has a history of complex ovarian cyst and uterine fibroids who underwent an exploratory laparotomy through a Pfannestiel incision for right salpingoophorectomy, abdominal myomectomy, and lysis of adhesions. The patient was admitted to the hospital on the day of procedure. The inpatient admission is under review.

The health plan's determination is overturned. The inpatient stay was medically necessary. This is a major surgical procedure, arguably generating a more intense recovery component than a Cesarean delivery or even hysterectomy. The incision used is 10-14 centimeters wide, identical to that used for Cesarean delivery. The patient requires parenteral pain medication usually for at least 24 hours, along with Foley catheter drainage usually until the morning after surgery (with subsequent observation for proper voiding after that). Although early feeding is the contemporary routine, most patients are not actually tolerating any kind of diet for at least 24 hours. Recovery is usually 4-6 weeks after the surgery. The potential for complications including bleeding, infection, bladder issues, and ileus is robust in the first 48 hours after surgery so it is not safe to discharge these patients any sooner than that.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Benign Prostate Hypertrophy 
 
Treatment: 53854-Transurethral Destruction of Prostate Tissue; by Radiofrequency Generated Water Vapor Thermotherapy (Rezum System)

The insurer denied the 53854-Transurethral Destruction of Prostate Tissue; by Radiofrequency Generated Water Vapor Thermotherapy (Rezum System). The denial was reversed. 

This is a middle aged male who has a history of mild prostatic enlargement, urinary infection, and gastroesophageal reflux. The medical record reports that the patient did not response well to medical treatment in the past. The patient reported rapid onset, slow resolution of slowness of his urine stream and frequency. His most recent Prostate Specific Antigen (PSA) was 2.3. The patient tried low dose alpha- blocker in the past but had to stop due to increased fatigue. 

According to the current peer-reviewed medical literature, Rezum radiofrequency thermal therapy offers a minimally invasive option for benign prostatic hypertrophy (BPH) management with moderate improvement in symptoms and flow rate.  The results from prior clinical studies appear to be independent of prostate size or presence of a median lobe, and patients are largely satisfied.  Results are similar for both obese and non-obese subjects.  The thermal therapy warrants positioning as a procedure for lower urinary tract symptom relief, both as an initial therapy vs medications and as an alternative to transurethral surgery for select patients.  The literature indicates that a single water vapor thermal therapy procedure provides effective and durable improvement in symptom scores with lower observed clinical progression rates. Furthermore, in a pivotal trial utilizing 188 subjects, Rezum treatment resulted in the preservation of sexual function.  

The carrier's denial of coverage for 53854-Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy (Rezum System) should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mild Displaced Communicated Fractures of the distal Tibial and Fibular Diaphysis
 
Treatment: Inpatient Hospitalization

The insurer denied the Inpatient Hospitalization. The denial was reversed. 

This is a male patient who presented to the emergency department (ED) after sustaining a fall on his motorcycle. A left leg x-ray revealed fractures of the distal tibial and fibular diaphysis. A computerized tomography (CT) of his left leg was performed which showed mild displaced comminuted fractures of the distal tibial and fibular diaphysis. There was no compartment syndrome noted.  He was evaluated by orthopedics, surgery was recommended. He underwent an intramedullary nailing of his tibial shaft fracture without complications. He was evaluated by physical therapy and occupational therapy. It was determined that he have outpatient occupational therapy. The patient was discharged home safely with follow up instructions.

The medical record demonstrates the patient sustained a traumatic injury that required emergent surgical intervention. His fracture was displaced and required stabilization. This type of injury is prone to swell.  There is risk of compartment syndrome. The application of ice and elevation would be required prior to surgery. He would require narcotic analgesia.  He was evaluated on a timely basis and surgery was completed the next day.  It would not be feasible to splint the extremity and have the man scheduled as a semi-elective procedure. His operation was complex and extensive enough to warrant the post-surgical day.

Based on the above, the medical necessity for the inpatient hospitalization admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis (inverse)
Treatment: Tacrolimus ointment
The proposed Tacrolimus ointment is medically necessary.  

Use of topical calcineurin inhibitors is considered standard of care in sensitive areas including the groin.  This is clinically appropriate, considered safe and effective, not for the convenience of the patient or provider.  Alternatives (chronic use of steroids) are not appropriate.
Appeal type: Medical necessity
Decision: Overturned

This is patient, female to male transgender. The patient desired top surgery to assist with his transition. His therapist supported the decision for top surgery. His surgeon performed transgender breast mastectomies. The health plans determination is overturned in whole. Yes, the procedure should be a covered benefit because mastectomies were medically necessary.
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
Criteria for mastectomy and creation of a male chest in Female to male (FtM) patients:
1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
4. If significant medical or mental health concerns are present, they must be reasonably well controlled.
Hormone therapy is not a prerequisite.
Regarding chest surgery for adolescents, WPATH guidelines are as follows: "Chest surgery in FtoM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identity expression."The patient meets these guidelines.The standard of care for adolescent top surgery is met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Quadriceps rupture
Treatment: Inpatient admission 
The Inpatient admission was medically necessary.

Summary:
The patient is a male who sustained injury to his right knee. He had fallen down stairs and was unable to ambulate. He was brought by EMS to hospital.  

The medical record demonstrates the patient underwent an open surgical procedure with many associated comorbidities (diabetes, hypertension). He presented to ED with the diagnosis of quadriceps rupture. He required medical evaluation with additional testing (echocardiogram). His procedure required a large incision with drilling to his patella. Several sutures were placed in damaged tendon with surgery being completed. He required post-surgical analgesia of Morphine.

The patient was anesthesia grade 3, which would place him at increased risk for complications. He was obese and would be expected to have difficulty with ambulation. A wheelchair was recommended with subacute rehab discussed. He required a brace. 

These associated conditions substantiated the necessity of admission and length of stay. Observation status would not have been applicable, as one would not have expected a benign medical course in this patient's case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations and chest discomfort 

Treatment: Inpatient admission 

The insurer denied coverage for Inpatient admission. The denial was upheld.

This patient is a woman who had a history of palpitations and chest discomfort, with a loop recorder implanted in early 2019 and exercise stress echocardiography in early 2019, revealing no regional wall motion abnormalities but 1 mm ST segment depressions at peak stress.  She had no significant past medical history, and home medications only included low dose aspirin daily.  She developed recurrent chest discomfort in early to mid-2019, described as mid sternal, intermittent, and sharp, awakening her from sleep.  One week prior to presentation, the chest discomfort changed to a more constant dull ache, and she was seen by Cardiology in mid-2019, who recommended diagnostic coronary angiography.  The discomfort increased over two days, and she presented to the ED on the second day.

Initial vital signs included blood pressure 160/103, heart rate 71, temperature 98.7 F, and oxygen saturation on room air 100%.  EKG was normal and chest x-ray only revealed a prominent right hilar region.  Laboratory test results revealed white blood cell (WBC) count 7.9, hemoglobin 13.3, creatinine 0.72, and troponin level <6 (negative). CT scan of the heart and coronaries revealed mild coronary artery calcium with minimal (<30%) calcified and non-calcified plaque in all three major coronary artery distributions.  She was discharged to home on atorvastatin and aspirin.

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome.  This could have been completed in the Emergency Department or an observation level of care, followed by outpatient testing and management.  The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Suicidal thoughts
Treatment:  Continued inpatient admission 

The proposed treatment was not medically necessary.

Although this chronically disturbed patient presented an ongoing low level risk of self harm, by the dates in question he denied suicidal plan, intent, or ideation.  He did not show evidence of danger to self or to anyone else in the hospital.  The documentation does not indicate that his chronic, deep-seated difficulties could improve in any significant way through yet another lengthy acute inpatient stay.  Nothing in the documentation reviewed indicates that this patient could not have been treated safely and effectively in a less intensive setting, such as the options suggested by the health plan.