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

Diagnosis: Cataract
Treatment: Cataract surgery
The insurer denied Extracapsular Cataract Removal with Insertion of Intraocular Lens. Prosthesis (CPT 66984-RT). The health plan's determination is overturned.

The patient is a female with history of diminished vision of the right eye who underwent cataract surgery. 

Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (CPT 66984-RT) is medically necessary for this patient. The patient had a visually significant cataract that required surgery to improve her visual outcome. The requested procedure was indicated in order to improve vision due to a progressive decrease in vision.
The cataract surgery would be necessary to remove the old cloudy lens and to allow a new intraocular lens prosthesis to be placed to restore vision.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute respiratory failure.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is the case of a male who presented with difficulty breathing. In the Emergency Room, the patient was noted to be in respiratory distress and placed on high flow nasal canula. On exam, the patient had crackles, wheezing, and retractions. His vitals included pulse 176, respiratory rate 34, and oxygen saturation was in the 80's, his labs were notable for a white blood count of 22,000 and positive endogenous retrovirus (ERV). The patient was admitted to pediatric intensive care unit for acute respiratory failure and started on Proventil. Bilevel positive airway pressure (BiPAP) was increased secondary to retractions, and the patient was started on intravenous (IV) Solumedrol 13 milligrams every 6 hours. He was weaned to room air and discharged.

The Milliman Care Guideline (MCG) admission guidelines (1) support admission when:
"Clinical indication for Admission to Inpatient care: Need for acute invasive or non-invasive mechanical ventilation Respiratory distress." This patient clearly had respiratory distress and needed ventilation support.

Consensus guidelines (2) also support the use of inpatient ventilatory support: "Noninvasive positive pressure ventilation can be beneficial in children with pediatric acute respiratory distress syndrome, particularly in those with milder disease." The entire admission was medically reasonable and necessary.

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 the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: mycobacterium avium complex (MAC) pulmonary infection
Treatment: Amikacin Inhalation Suspension (Arikayce)
The insurer denied Amikacin Inhalation Suspension (Arikayce).
The health plan's determination is overturned.

The patient is a female with refractory mycobacterium avium complex (MAC) pulmonary infection. Standard triple therapy for MAC was started based on pharmacy claims data. Arikayce was started. The patient has a history of bronchiectasis. Clofazimine was added to her existing regimen for MAC. Radiographic signs of bronchiectasis and MAC infection are markedly improved compared to prior on a recent chest CT (computed tomography). 

Amikacin Inhalation Suspension (Arikayce) is medically necessary for this patient who has seen negative culture conversion and reported benefit. Scientific guidelines recommend continued therapy for 12 months after a positive sputum culture. This patient has clearly demonstrated a conversion of positive sputum culture to negative within one year of starting therapy, and Arikayce should be continued to avoid relapse. Arikayce has been demonstrated to increase the probability of positive to negative culture conversion sustained at one year and improve 6-minute walk distance.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Multifibroid uterus
Treatment: Ambulatory surgery - radiofrequency ablation [0404T x (times) 1]
The insurer denied the Ambulatory surgery - radiofrequency ablation [0404Tx1].
The denial is upheld.

The patient is a female with complaint of heavy vaginal bleeding. Her hematocrit was normal (42.5). She is hypothyroid. The patient's ultrasound showed a submucosal myoma. Endometrial biopsy did not show any malignancy and suggested the presence of a polyp. She has not tried and failed any treatment.

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

It is unclear what is causing the patient's bleeding. In addition, based on the patient's hematocrit, the bleeding is not as severe as reported. Note that this patient has a polyp found on biopsy that could be causing her bleeding. Prior to proceeding with any surgical procedure, an attempt at treating the problem medically is warranted. Oral contraceptives, a levonorgestrel intrauterine device (IUD), Lysteda, Orihann are standard considerations prior to proceeding with the proposed treatment.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.

Standard of care prior to the requested treatment includes consideration of a trial of oral contraceptives, levonorgestrel intrauterine device (IUD), Lysteda, Orihann, or hysteroscopic resection of the myoma. Note that the patient is not anemic suggesting that the bleeding is not as heavy as reported. In addition, the biopsy showed a polyp that could be causing the heavy bleeding.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-neck and left arm pain.
Diagnosis: Cervical/thoracic Epidural Injections. 
The health plan denied Epidural Injections.
The denial is upheld.

This is a male with a history of neck and left arm pain. He has had physical therapy, injections and medications without relief. He is a non-smoker. He has had multiple left cervical (C)7-thoracic (T)1 epidural steroid injection (ESIs). The neurologic exam shows no motor deficits but decreased sensation in left C8. No magnetic resonance imaging (MRI) report has been provided. The patient saw a neurosurgeon who recommended an MRI, however no report or follow up was provided. The provider has recommended a left C8 ESI performed. The subject under review is the medical necessity for cervical/thoracic epidural injections.

The health plan's determination is upheld.

No. The procedure is not medically necessary. No cervical MRI report has been provided. There is a note from a neurosurgeon recommending an MRI but no follow up was provided. The patient would need adequate imaging studies before an epidural steroid injection. Additionally, the patient has undergone multiple injections at this level, and there should be further consultation with a neurosurgeon after an MRI to see if surgery is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System - pneumothorax. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a male who was admitted to the hospital for a pneumothorax. He has a past history of seizures, Brugada syndrome and pneumothorax. On presentation had worsening dyspnea. Vitals were significant for a heart rate of 103. Chest x-ray noted a large left sided pneumothorax. An emergent chest tube was placed, and the patient was admitted to the hospital with appropriate pain control. His home medications were continued. The chest tube was taken off suction and placed to water seal. Pneumothorax resolved and the chest tube was removed. The patient was also found to be coronavirus (COVID) positive and asymptomatic from this. His condition resolved and he discharged in stable condition. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient.
The patient in question does meet medical necessity for the acute inpatient level of care per Milliman Care Guidelines (MCG) criteria as the pneumothorax was associated with exacerbation of a significant comorbidity. The patient's Brugada syndrome could have potentially worsened with this and required close monitoring. Additionally, according to Sahn et al., (2000) and Bintcliffe et al., (2015) the patient required chest tube placement for a large pneumothorax and close monitoring due to multiple comorbid conditions. It appears to be most appropriate per current literature and standard of care for the patient to be acute inpatient status and not at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis

Treatment: Dupixent 300 milligrams/2 milliliters (mg/2 ml) subcutaneous (SC) solution prefilled syringe (SOSY)

The insurer denied coverage for Dupixent 300 mg/2 ml SC SOSY.

The denial is overturned.

The patient is a male with atopic dermatitis (AD) affecting more than 50% (percent) total body surface area (TBSA) which includes the face, scalp, trunk, and extremities and an Immunoglobulin A (IgA) of 4. The patient has failed topical therapy with topical steroids, tacrolimus, elidel, and Eucrisa. The patient has failed therapy with oral prednisone and Benadryl. The requested medication is Dupixent.  

The patient has severe AD that involves a large surface area requiring systemic therapy. The patient requires systemic therapy given the extent of involvement and the use of Dupixent would appear to be reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of AD and the inability to use systemic light therapy due to sensitive areas of involvement. The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is the only systemic therapy approved by the FDA for the management of AD. In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments. (1-3) According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment... with moderate-to-severe AD who are uncontrolled with topical therapies". (1) As such, the decision is reversed and Dupixent is approved at the medical discretion of the physician based on the standard of care and the provided medical documentation.   

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

The insurer's denial of coverage for Dupixent 300 milligrams/2 milliliters (mg/2 ml) subcutaneous (SC) solution prefilled syringe (SOSY) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal, Altered Mental Status.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a past medical history (PMH) of alcohol abuse who was admitted with complaints of (c/o) altered mental status and intoxication. His vital signs were unremarkable. The physical exam was notable for tremors. Lab work was notable for ethanol 441, pancytopenia. The patient was diagnosed with alcohol withdrawal and treated with intravenous fluids (IVF), thiamine, oral librium, and Clinical Institute Withdrawal Assessment (CIWA) protocol and Ativan. The maximum CIWA score was documented to be 19. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

Yes, the hospital stay was medically necessary at an acute inpatient level of care. 

The patient had a medical history and physical exam clinically concerning for acute alcohol withdrawal with c/o altered mental status. This presentation was further compounded by the patient's high CIWA score of 19, and these types of patients are not appropriate for a lower level of care due to the close clinical monitoring that is required to ensure no respiratory depression and adverse events, especially in the setting of clinical concern for seizures in this patient population. Due to the patient's acute, non-mild alcohol withdrawal requiring treatment with benzodiazepines, the patient required close clinical monitoring for potential intervention that could not have been safely provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Epilepsy
Treatment:  XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The insurer denied the XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The denial is overturned

This is a female who carries a diagnosis of primary generalized epilepsy for which authorization of coverage for treatment with cenobamate is sought.

The plan should cover the proposed treatment.
The proposed treatment is a rational escalation after a number of trials of first-line treatments, in the setting of clinically and electrophysiologically confirmed refractory epilepsy.

The requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.

The patient has undergone treatment with first-line management approaches, and has demonstrated both intolerance and insufficient clinical response despite treatment escalation. Without further escalation the patient risks future seizures that could develop into status epilepticus with associated sequelae that include disability and mortality secondary to SUDEP (sudden unexplained death in epilepsy).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Epilepsy
Treatment:  XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The insurer denied the XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The denial is overturned

Patient is a female with primary generalized seizures currently on Topamax and Lamictal
who is currently experiencing significant side effects. She has tried and had side effects or failed multiple anti epileptic drugs. She has a wide array of seizure types including focal seizures with secondary generalization. She has daily focal seizures. Provider wishes to start Xcopri. The request was previously denied as it was considered experimental/investigative.

Yes, the health plan should cover the proposed treatment.
Xcopri is medically appropriate. A randomized control trial done by Krauss and colleagues showed that Xcopri was effective as an adjunct therapy. Patient has tried multiple medications for her seizures and they either are not effective or produce side effects. If patient's seizures are not well controlled this puts her at risk for status epilepticus or sudden unexpected death in epilepsy and it is important to try novel medications when standard of care treatment is not effective or is intolerant.

Yes. Patient has tried and failed or is intolerant to multiple anti-epileptic agents and is still having daily focal seizures and given that Xcopri has been shown to be safe and effective, it is more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Epilepsy
Treatment:  XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The insurer denied the XCOPRI 12.5-25MG (milligram) Tab (tablet) DS PK (dose pack), pre-service
The denial is upheld

The member is a female with generalized seizure disorder. She has tried and failed levetiracetam. She is currently treated with clobazam, lamotrigine and topiramate. The provider is requesting Xcopri. The requested medication was denied coverage as the member does not have a diagnosis for which use is FDA (Food Drug Administration) approved and use is not supported by appropriate compendia for her condition.

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

The medical records and EEG (electroencephalogram) document a diagnosis of generalized seizure disorder. The requested medication, Xcopri is not FDA (Food Drug Administration) approved for this condition. Moreover, there are no clinical trials indicating that it is effective for persons with generalized seizure disorder or both generalized and focal seizure events. Therefore, use here is not consistent with standard of care (Abou-Khalil).

No. The requested medication is not more beneficial than any standard treatment for the insured's condition or disease.

There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Xcopri relative to any other available anticonvulsant.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis (DKA).
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned.

The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.

Vital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.

White blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.

Chest x-rays revealed (CXR) revealed B/L airspace disease.

The patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx). 

Repeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.

The patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.

This patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation. Based on above, it was appropriate to admit this patient to the hospital for active treatment and very close monitoring. This patient was not stable to be treated in any other setting.

This patient decided to sign out against medical advice (AMA), which was not in any one's control. He was not stable at the time he absconded from the hospital.

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 inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is upheld.

The patient is a male with a past medical history significant for hypertension and hyperlipidemia who presented with a diffuse pruritic rash as well as foreskin issues.
The patient had a history of eczema rash in the past. At some point, it was in remission but returned in the areas including the upper chest and hands. He also complained of swollen foreskin and inability to retract his penis along with some scanty discharge. The subject under review is the medical necessity for the inpatient stay. 

The inpatient admission was not medically necessary for this patient.
The patient presented to the hospital with a several-week history of worsening skin rash consistent with eczema. He had been already diagnosed with eczema in the past. Eczema is a chronic condition associated with flareups and remissions. This is not a dermatologic emergency. The treatment of eczema is usually conducted as an outpatient.
Another clinical problem was balanitis, which is also a condition not requiring admission at the acute inpatient level of care.
Even though the patient had positive urine culture, there was no evidence of hemodynamic instability or inability to take oral antibiotics. The patient had no significant electrolyte abnormalities or abnormal kidney function.
The patient had clinical signs of uncontrolled diabetes, which was confirmed by laboratory studies. However, he refused to take insulin after discharge and therefore did not need the teaching of insulin injection technique.
Furthermore, even though his diabetes was uncontrolled, there was no evidence of a true glycemic emergency.
Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the provided services rose to the level of acute inpatient care.
The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System. Gastrointestinal - Diarrhea and heartburn.
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission.
The denial is overturned. 

This is a female with a past medical history of hypertension, diabetes, dyslipidemia, and a history of chronic microcytic hypochromic anemia presents with melena preceded by a week of diarrhea and heartburn. Labs on admission revealed positive fecal occult blood (FOBT), anemia, azotemia, and hypokalemia. The patient was admitted to the inpatient floor and received intravenous (IV) fluids, IV protonix and potassium supplementation. A gastrointestinal (GI) consultation recommended a diagnostic esophagogastroduodenoscopy (EGD). Diagnostic EGD revealed gastritis.
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Admission was medically necessary for this patient.
Inpatient medical care was necessary. This patient with significant comorbidities presented with suspected upper GI bleed in the setting of positive FOBT and microcytic anemia. Her clinical presentation required acid suppression, serial monitoring labs, and GI consultation with endoscopy. Delay in medical management and evaluation of melena and hypokalemia can result in hypovolemia, shock, and death. Therefore, this detailed inpatient care (IV fluids acid suppression, potassium supplementation, GI consultation, and diagnostic endoscopy) cannot be prudently provided at any other level of care without increasing mortality or morbidity in this high-risk patient. She was at risk for complications of GI bleed which include hypovolemia, end organ dysfunction and death.
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary.