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

Diagnosis: Gynecological
Treatment: Inpatient Hospital
The insurer denied inpatient stay.
The denial is upheld.

The patient was a gravida (G) 0 with a last menstrual period of 3 weeks prior who presented with left lower quadrant pain on the afternoon of presentation. She had been previously seen in the emergency department 4 days prior and sent home with pain medication which included Toradol and Tylenol alternating. The patient had been taking the medication every 6 hours and was reporting that the pain was now 12 out of 10 and radiated to the left back. It was painful to urinate, and she was only able to urinate in small quantities. She had no nausea, vomiting, chills or fever. She denied any vaginal bleeding or discharge and reported eating a steak at night. The patient denies any obstetric history. Her gynecologic history was noted for small ovarian cyst and irregular periods. She had been previously on oral contraceptives but stopped due to weight gain. She was not sexually active. Past medical history was noted for morbid obesity. The patient's medications included vitamin D. Past surgical history noted a Roux-en-Y gastric bypass. There were no known allergies.

The patient was taken to the operating room where the abdomen was entered via laparoscopic approach with the left adnexa noting a large tortuous paratubal cyst that had the intraperitoneal ligament torsed 2 times. The ovary was 5 cm (centimeters), purple, and edematous, but not necrotic. There was drainage of 2 liters (L) of serous fluid from paratubal cyst. There is a normal uterus and right tube and right ovary. A left salpingectomy was performed using LigaSure. Hemostasis was achieved and the left ovary was tucked within the cul-de-sac. The patient had 10 milliliters (mL) of blood loss and 500 mL of intravenous (IV) fluid. Patient was discharged home following surgery with outpatient follow-up scheduled.

The health plan's determination is upheld.

The acute inpatient admission was not medically necessary at the acute inpatient level of care status for this patient given the diagnosis of stable left sided paratubal cyst undergoing left salpingectomy via laparoscopy with stable vital signs. The American College of Obstetrics and Gynecology (ACOG) recommend that the care for salpingectomy for torsion does not require acute inpatient medical care. In this case, the patient met the ability to have pain controlled with oral medications, tolerate regular diet, and ambulate. She had no limitations to understanding post operative instructions. Thus, she was eligible for treatment at a lower level of care followed by discharge to home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder Pain, Right

Treatment: procedure codes 97813 (2 units) acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient and 97814 (4 units) acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

The insurer denied coverage for procedure codes 97813 (2 units) acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient and 97814 (4 units) acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).

The denial is upheld.

This is a patient with right shoulder pain.  Treatment included acupuncture with reported improvement.  Under review is the medical necessity of the acupuncture treatment provided.

The acupuncture treatment notes provide insufficient objective clinical information to support the medical necessity for continuation of the services under review.  There are no quantitative or verifiable measures of improvement.  There is no evidence the treatment is expected to result in significant therapeutic improvement over a clearly defined period of time. The treatment plan is not individualized or appropriately correlated with the medical records and the individual's exam.  There are no documented treatment goals that are functionally oriented, measurable, and evidenced based.  To the contrary, the treatment plan repeatedly documents "Patient is improving as expected and should continue with present treatment plan," which is non-specific and does not support medical necessity.  

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

From a physical medicine & rehabilitation/pain management perspective, the requested 97813 (2 units) acupuncture and 97814 (4 units) acupuncture was not medically necessary. 

The insurer's denial of coverage for procedure codes 97813 (2 units) acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient and 97814 (4 units) acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sore Throat and Fever. 
Treatment: Inpatient Admission. 

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

The patient is a female with a history of sore throat and fever. 

The patient's pulse was 146. WBC (white blood count) was 8.7. The patient was treated with exudative tonsillitis and discharged on Augmentin. 

The patient presented back with a fever of 102.9 with difficulty swallowing. CT (computed tomography) reported lymphadenopathy and retropharyngeal phlegmon vs abscess. Medical therapy included IV (intravenous) Zosyn and Decadron. The patient was transferred to the ICU (intensive care unit) for tachycardia and tachypnea. ENT (otolaryngology) evaluation did not recommend surgery. IV (intravenous) antibiotics were changed to IV (intravenous) Unasyn and Vancomycin. The patient improved and was sent home. 

Coverage for the inpatient stay was previously denied by the health plan, and the provider is appealing the denial. 

No, the Inpatient admission was not medically necessary. 

All records were reviewed. The patient was seen in the ED (emergency department) for a second time after having been discharged from the ED (emergency department) with Augmentin for tonsillitis. The patient's throat symptoms had worsened. The patient had an elevated temperature on presentation with tachycardia. WBC (white blood count) was 8.7. CT (computed tomography) reported lymphadenopathy and retropharyngeal phlegmon vs abscess. ENT (otolaryngology) did not recommend surgical drainage. The patient was started on IV (intravenous) antibiotics and steroids. 

There was no hemodynamic instability and no difficulty with the patient managing her own secretions. There was no oxygen desaturation, and the patient was started on a regular diet. Therefore, based on the information provided, the medical necessity of the inpatient stay cannot be confirmed, as the patient's care could have been rendered 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: Formulary Exception
Decision: Upheld

Diagnosis: Erectile Dysfunction (ED)

Treatment Stendra (avanafil)

The insurer denied coverage for Stendra (avanafil)

The denial is upheld

This is a male with history of benign prostatic hypertrophy (BPH), erectile dysfunction (ED), diabetes, hypertension, irritable bowel syndrome (IBS), hyperlipidemia, varicose veins. The patient suffered from nocturia / erectile dysfunction - physician office received continuing on Cialis. He received Stendra for treatment of ED.

As per the clinical records, on progress note states the patient has used Cialis, Viagra in the past but got headaches from each of these medications. However, progress note stated that "Cialis 5 mg (milligrams) oral has helped lower urinary tract symptoms (LUTS) and erectile dysfunction both." The clinical documentation supports efficacy of Cialis 5 mg oral for treatment of benign prostatic hypertrophy / erectile dysfunction. Stendra usage also reports 5-10% (percent) risk of headache, very similar to the headache side effects of sildenafil, tadalafil. 

As summarized in Up to Date "All four phosphodiesterase type 5 (PDE5) inhibitors (avanafil, sildenafil, vardenafil, and tadalafil) work to sustain levels of cyclic guanosine monophosphate (GMP) within the penile corpora cavernosa to allow men with ED to achieve erections in response to appropriate sexual stimuli. Sildenafil, vardenafil, tadalafil, and avanafil result in similarly high rates of successful sexual intercourse (68 to 69 percent compared with 33 to 35 percent for placebo) and similar side-effect profiles" (3)

Request for formulary exception for Stendra is denied. Medical records do not support failure of Cialis tab to successfully treatment erectile dysfunction. No evidence that the requested drug is more effective than the formulary drug. It has similar risk of headache, may be slightly faster acting. Formulary drugs have been effective, caused the same side effective as the requested drug.

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

The insurer's denial of coverage for Formulary Exception for Stendra (avanafil) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting (alcohol).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a history of alcohol abuse and dependence, anxiety disorder, depression, and gastroesophageal reflux disease. He presented with vomiting, cough, and runny nose. He had tried to stop drinking. His last drink was the day prior to arrival.

The patient's Vital Signs were as follows: Temperature 36.7, Pulse 134, Respiratory Rate 20, Blood Pressure 110/95, Pulse oxygenation 97%. The patient's exam was unremarkable. The patient's labs revealed the following: White blood cells (WBC) 9.6, Hemoglobin/Hematocrit (H/H) 17.4/49, Platelet (Plt) 117, Sodium (Na) 135, Potassium (K) = 3.4, Blood urea nitrogen/Creatinine (BUN/Cr) 23/2.36, Glucose 199, Ethanol < 10, Magnesium 1.3. The patient's EKG (electrocardiogram) revealed sinus tachycardia.

The patient was admitted with alcohol withdrawal. Plan of care included IVF (intravenous fluids) and CIWA (clinical institute withdrawal assessment) protocol.

On day two, the patient's vital signs were stable. His HR (heart rate) was 106. He was in no acute distress. BUN/Cr (blood urea nitrogen/creatinine) was 19.3/1.06.

On day three, the patient's vital signs were stable. He was in no acute distress. His hands were slightly tremulous.

No, the Inpatient admission was not medically necessary.
This patient with a history of alcohol abuse was admitted with alcohol withdrawal. He was not acutely intoxicated. The patient was hemodynamically stable and afebrile. He had mild tachycardia but no arrhythmia. He did not have findings of severe alcohol withdrawal. Labs were remarkable for acute kidney injury that resolved on day #2 after IV (intravenous) fluids. He did not have severe electrolyte abnormalities.  He did not have comorbid conditions. The patient was admitted with plan for CIWA (clinical institute withdrawal assessment) protocol. During hospital stay, his tachycardia resolved. He was tremulous but did not have signs of severe alcohol withdrawal. He had not failed a lesser level of care. The patient was clinically stable and did not have findings of severe alcohol withdrawal. He did not have symptoms that required an acute inpatient level of care. The acute inpatient level of care was not medically necessary.

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: Family History of Factor II Mutation
Treatment: Genetic Testing
The health plan denied the Genetic Testing
The determination is upheld.


The patient has a Factor II (prothrombin G20210) mutation. He has an upcoming hypospadias repair under anesthesia and the provider has recommended testing him for the Factor II mutation, noting that the surgery and immobility can predispose him to hypercoagulability. The use of Factor II genetic testing is under review.
The requested health service / treatment with genetic testing is not medically necessary for this patient.
This patient has no personal history of thrombosis and has one first-degree relative with a genetic mutation that might predispose to thrombophilia with his mother's Factor II mutation. The provider has stated that the genetic testing is necessary in this infant due to his upcoming surgery and risk for potential thrombosis with immobility. However, as a infant is unlikely to have clear mobility issues following this type of surgery, and the weak thrombotic risk for heterozygous Factor II mutation alone, this is not clearly clinically indicated at this time. There are limitations to thrombophilia genetic testing in children who are unable to make an informed decision of their own about this testing, and when there is currently no demonstrated benefit to inherited thrombophilia testing in childhood. The maternal genetic history is provided, but not the maternal clotting / thrombosis history. If the mother has a history of thrombosis, and the child is tested for Factor II testing and is found to be negative, this is not going to definitively tell the provider that the infant is or is not going to develop a thrombosis postoperatively.
In general, it has been stated that there is little evidence to support the use of thrombophilia testing in asymptomatic children with a family history of thrombosis, as well as those with a family history of a thrombophilia mutation. One previous study by Tormene et al noted that 18 children with a single thrombophilia factor in a family with an individual with a thromboembolism showed that no events occurred in the patient, despite acquired risk factors such as surgery and trauma.
While genetic testing has become quite common in this clinical situation, the medical benefits are quite limited. The World Health Organization's (WHO's Review of Ethical Issues in medical Genetics recommends that genetic testing in general should only be carried out if there are potential medical benefits, and the American Academy of Pediatrics (AAP) and the American College of Medical Genetics (ACMG) recommend against the use of predictive genetic testing for these types of situations. There is very little chance for thrombophilia testing to be of benefit in a young child (0.07/100,000) and anticoagulation in this setting would not typically be performed even in the setting of a positive mutation.
Therefore, based on the clinical information provided for review, the current standards of care, and the peer-reviewed medical literature, the recommended Factor II testing is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Tooth Loss/edentulism
Treatment: Dental/Orthodontic Procedure-Implants and abutments
The health plan denied the dental treatment of Implants (surgical implant placement and prefabricated implant abutment) as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient presents to the office of her dental provider for evaluation and treatment of her entire mouth for complete edentulism. In question is the medical necessity of the planned treatment of implants in sites # (number) 22 and 27 (6010), and abutments for each implant (6056) to retain a mandibular denture.

The requested health service/treatment of implants (surgical implant placement and prefabricated implant abutment) teeth #22 and #27 are medically necessary for this patient. As the patient has a severely resorbed ridge with diagnosed lack of retention and stability, there is no other way for the mandibular denture to be used in the mouth without it coming from dental implants. Hence, they are necessary for the patient to retain the denture and to use the denture, as dental implants provide support, stability, and retention for the prosthesis.

The medical provider has established issues with the gastrointestinal (GI) system secondary to inability to chew the appropriate foods and the treating dentist has diagnosed severe resorption of the mandibular ridge with radiographic evidence to substantiate this.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension.

Treatment full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is upheld.

This is the case of a male that presented to the hospital with left sided neck pain radiating to the chest after heavy lifting at work. Upon arrival to the hospital, vital signs were stable with blood pressure (BP) of 179/89 and heart rate (HR) 73. Physical exam was significant for reproducible tenderness along the left side of the neck and left trapezius muscle. A 12-lead electrocardiogram (EKG) revealed no evidence of acute ischemia. Serum blood testing revealed no elevation in troponin (peak- 0.05 ng/ml [nanogram per milligram]). Computed tomography (CT) scan of the chest revealed no abnormality. The patient was admitted to the hospital for observation and treatment of hypertension. He was ultimately discharged home two days later on medical therapy.

This patient presented with atypical chest pain and a past medical history of hypertension. Symptoms were reproduced with palpitation on physical exam. His pretest probability of coronary artery disease was low (1). Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score he was considered low risk (2). Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on EKG was reviewed by Hedayati et al. (3) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization within the two weeks following presentation. In conclusion, this patient could have been treated at a lower level of care.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Surgical Menopause.
Treatment: Testosterone Gel.
The insurer denied Testosterone Gel.
The determination is upheld.

This is a patient with surgical menopause. There are notes indicating hormone replacement with estradiol and testosterone cream. She was monitored for cholesterol and estrogen/testosterone levels. There are no office notes regarding its first use including symptoms and treatment effects. She would like Testim, a testosterone medication Food and Drug Administration (FDA) approved for men.
At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.

The formulary testosterone gel will be as effective as the non-formulary drug.
The patient  has been receiving testosterone cream dosed down for female use, however, there is a lack of medical documentation that the formulary cream is needed. There are notes regarding estrogen/testosterone use for several years, however, no notes regarding the symptoms or effects. Therefore, there are no notes regarding the need for non-formulary options.
Testosterone therapy in women is not FDA approved and short-term use of transdermal testosterone can be considered as a treatment option for postmenopausal women with sexual interest and arousal disorders who have been appropriately counseled about the potential risks and unknown long-term effects. No such documentation exists in the records provided. If transdermal testosterone therapy is used in postmenopausal women with sexual interest and arousal disorders, a 3-6-month trial is recommended with the assessment of testosterone levels at baseline and after 3-6 weeks of initial use to ensure levels remain within the normal range for reproductive-aged women. Transdermal testosterone therapy should be discontinued at 6 months in patients who do not show a response. Again, no documentation of response is provided. The long-term safety and efficacy of transdermal testosterone have not been studied and evidence is insufficient to recommend for or against testosterone for the treatment of sexual interest and arousal disorders in premenopausal women and expert consensus guidance from the Endocrine Society and the North American Menopause Society are not supportive of their use for the treatment of female sexual dysfunction. Therefore, the formulation is non-FDA approved and therefore no evidence that non-formulary medications work better with less side effects.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension. 
Treatment: Eliquis. 

The insurer denied Eliquis. The health plan's determination is upheld. 

The patient is a male with a history of pulmonary embolism, hypertension, and coronary artery disease (CAD). The use of Eliquis is under review. 

A formulary exception is not indicated. 

The formulary drugs include Xarelto and warfarin. There was no treatment failure to these medications. Xarelto would be as effective as Eliquis. Those with pulmonary embolism generally require long-term anticoagulation. The new direct oral anticoagulants, including Xarelto and Eliquis, have been demonstrated safer than warfarin towards decreased risk of bleeding, and are generally more effective for anticoagulation. Additionally, in this case there was no contraindication to Xarelto. Therefore, Eliquis is considered not medically necessary. The patient can try the formulary medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 
The insurer denied additional physical therapy services. 
The insurer's determination of overturned.

The patient is a  female with right rotator cuff tendinopathy who started outpatient physical therapy, and attended 21 visits. Two additional visits were approved however the provider requested two additional visits which according to the final adverse determination letter, these were denied, and the approval remains at two visits. The subject under review is the medical necessity for the two additional requested visits. 

An additional two physician therapy (PT) visits are necessary as this patient continues to have pain with range of motion, reduced strength of the right shoulder, and functional deficits due to pain and weakness. The health plan claims there is no progress being made in therapy. They claim her strength is limited at 4/5, range of motion is limited, and functional deficits persist. They say there has been no progress and there are no attainable goals. There is underlying postural dysfunction which contributes to pain which is limiting strength and range of motion (ROM). Goals include postural re-education and correction of scapula alignment and neuromuscular retraining of scapulothoracic rhythm. A skilled therapist is required to continue working on pain reduction, range of motion, and functional tasks such as lifting and reaching. There is expectation that the patient can improve with additional therapy.