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

Diagnosis: withdrawal symptoms

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is overturned. 

This male patient has a history of alcohol use disorder, opioid use disorder in remission, and depression.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.
The US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment , if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent.
According to the Level of Care for Drug and Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol, needed detoxification medication including Librium  and needed one day of observation without withdrawal symptoms or detoxification medication as he was considered a high risk for more severe withdrawal, complicated, and even life threatening withdrawal such as delirium tremens due to his large amount of daily alcohol use. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the time in this hospital setting for detoxification as he was discharged to an inpatient rehabilitation treatment.  

The health plan did not act 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 overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic left knee anterior cruciate ligament (ACL) rupture and left knee medial meniscus tear

Treatment: arthroscopy with meniscectomy

The insurer is denied coverage for arthroscopy with meniscectomy

The denial is overturned. 

This male patient has a history of chronic left knee ACL rupture and left knee medial meniscus tear.

The indications for meniscectomy include a defined pain generator and failure to improve with conservative management. Isolated meniscectomy in the presence of arthritis without mechanical symptoms is not recommended. The patient has an unstable knee. He has a chronic ACL deficiency with associated meniscal pathology. He was found to have an "old bucket handle" tear to the meniscus. It would be medically necessary to remove this mechanical impediment to normal joint mechanics. This should be performed regardless of an arthritic process. Isolated ACL reconstruction without removal of the damaged meniscal flap would likely result in ongoing giving way and locking. He has a unique clinical condition which has to be taken into consideration. 

The standard of care is the partial meniscectomy with ACL reconstruction. 

Criteria are only applicable in the absence of mechanical symptoms.

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

The carrier's denial of coverage for the arthroscopy with meniscectomy is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: major depression

Treatment: transcranial magnetic stimulation (TMS) treatment with treatment planning (code 90867), treatment delivery and management per session (code 90868), and redetermination of resting motor threshold and TMS session delivery (code 90869).

The insurer is denied coverage for transcranial magnetic stimulation (TMS) treatment with treatment planning (code 90867), treatment delivery and management per session (code 90868), and redetermination of resting motor threshold and TMS session delivery (code 90869).

The denial is overturned. 

This male patient has a history of major depressive disorder and schizophrenia.

Transcranial magnetic stimulation therapy was cleared by the Food and Drug Administration (FDA) in October 2008 and was indicated for the treatment of major depressive disorder in patients who failed or who did not have satisfactory improvement from 1 past antidepressant medication at or above minimal effective dose and duration in the current episode. Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham controlled trial ever conducted with transcranial magnetic stimulation therapy. This was the principal study for the FDA's approval of transcranial magnetic stimulation therapy for major depressive disorders. In addition, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Major Depressive Disorders considers TMS therapy as an appropriate acute phase option for patients who do not respond adequately to pharmacotherapy or psychotherapy and who are considered treatment resistant. The standard recommendation for TMS treatment is for patients who failed or who did not have satisfactory improvement from 1 past antidepressant medication at or above minimal effective dose and duration in the current episode.
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the transcranial magnetic stimulation (TMS) treatment with treatment planning (code 90867) treatment delivery and management per session (code 90868), and redetermination of resting motor threshold and TMS session delivery (code 90869) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abnormality of gait and poor safety

Treatment: personal care services, Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week

The insurer has denied coverage for personal care services, Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week.

The denial is overturned. 

This female patient has a history of multiple falls in the home, anemia, hypertension, congestive heart failure, constipation, depression, anxiety, vitamin B12 deficiency, osteoarthritis, spinal stenosis, hyponatremia, colitis, gastroesophageal reflux disease, coronary artery disease, muscle weakness, abnormality of gait and poor safety.

The insurer has denied coverage for personal care services, Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week. In their Final Adverse Determination letter they stated the request to increase services was denied because it was not medically necessary. The insurer explained that the patient had two independent home evaluations, and neither of them showed that the patient needed more than 40.7 hours of services per week. The insurer stated the patient is now receiving 46 hours per week. The insurer also stated they will continue to look at the patient's situation and make any changes necessary to maintain her health and independence.
The patient needs extensive-maximum assistance with all functions except bed mobility (limited). She has increased frequency of incontinence than in the past, and cognitive function is poorer. She has no informal caregiver during the day [she does not live with her daughter]. The patient has multiple personal care services requirements, and the increase in hours is approved. Her needs are not just safety and monitoring.

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

The carrier's denial of coverage for the personal care services, Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: appendicitis

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is upheld. 

This is a female patient with no significant past medical history.

Peer-reviewed literature indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis. Admission may be necessary for patients with severe systemic illness (example, sepsis), poorly controlled comorbidities (example, chronic obstructive pulmonary disease, chronic heart failure), or complications from the procedure (example, infection, bleeding) that require more than 24 hours of postoperative care. 

The patient underwent an uneventful laparoscopic appendectomy. There were no immediate complications documented after the surgery. She did not require more than 24 hours of postoperative care, and she was discharged within this time frame. According to clinical documentation, the patient was treated under observation standards.

The health plan did act 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: Pelvic Congestion Syndrome
Treatment: Lupron Depot
The insurer denied Lupron Depot. 
The health plan's determination is Upheld.

The patient is a female with pelvic pain who had a dilation and curettage, intrauterine device (IUD) removal. Pathology was negative. Postoperatively, she did well, and Lupron was discussed as well as cryoablation. A pelvic ultrasound was also normal.
Under review is the use of Lupron Depot.

Lupron Depot is not medically necessary for this patient.
Lupron Depot is medically necessary in the treatment of endometriosis or uterine leiomyomas. However, there is no indication that the patient has either of these conditions and a pelvic ultrasound was negative. There is also no indication of chronic cyclical pain with her menstrual cycle, nor a surgical procedure demonstrating known endometriosis. Lupron Depot can also be utilized to treat porphyria with menstrual aggravation which is also not demonstrated by these medical records. Other indications for Lupron Depot therapy including cancer and puberty related diagnosis. The patient has some pelvic pain possibly related to her IUD; however,' the etiology has not been adequately resolved. Lupron Depot therapy is not a treatment for pelvic pain and therefore the medication is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured Femur.
Treatment: Continued Skilled Nursing Facility stay.
The insurer denied the Continued Skilled Nursing Facility stay.
The health plan's determination is overturned.

The patient is a  male with medical history significant for cirrhosis, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, morbid obesity, and pulmonary embolism (PE) who suffered a mechanical fall which resulted in a left mid/distal femoral shaft fracture. He underwent open reduction internal fixation (ORIF) of the left femur. He was WBAT (weight bearing as tolerated). He was discharged to skilled nursing facility.
Under review is the medical necessity of Continued Stay in a Skilled Nursing Facility 

The continued skilled nursing facility stay is medically necessary and appropriate for this patient. The patient is a male who sustained a left femur fracture requiring ORIF. He has a medical history significant for cirrhosis, COPD, peripheral vascular disease, PE and morbid obesity. The concerning factor is the documentation of worsening bilateral lower extremity edema. The provider noted that there was a requested visit by a nurse secondary to increased lower extremity swelling with occasional weeping. At that time, Lasix 80 milligrams (mg) twice daily (BID) was started. Labs and an echocardiogram were ordered but those results are not provided. Furthermore, furosemide was increased to 80 mg three times per day (TID). From a medical standpoint, this patient is not medically stable. He needs lab monitoring and physician follow-up regarding his edema and necessity of extremely high doses of diuretic. Continued skilled nursing facility stay is medically necessary. Once the patient is medically stable then he is appropriate to be discharged to a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unsteady gait
Treatment: Personal Care Assistant (PCA) Services: Continuous Care, Split-Shift Services.
The health plan denied Personal Care Assistant (PCA) Services: Continuous Care, Split-Shift Services. 
The health plan's determination is overturned.

The patient is an elderly female with past medical history of macular degeneration with legal blindness, unsteady gait, coronary artery disease, diabetes, history of falls, urinary tract infection (UTI), cognitive decline, hyperlipidemia, hypertension, osteoporosis, urinary incontinence, osteoarthritis, and transient ischemic attack (TIA) who had been assigned PCA (personal care assistant) services.

Personal Care Assistant (PCA) Services: Continuous Care, Split-Shift Services are medically necessary.
The patient had documented decline in functional status following the death of her husband as she was legally blind and had his assistance during the hours the patient did not have aide services. The patient subsequently had a fall with lumbar fracture resulting in even further decline in functional status. The patient's PCP, on several occasions, noted the medical necessity of Personal Care Assistant (PCA) Services: Continuous Care, Split-Shift Services. The patient has unpredictable and unscheduled needs in the overnight hours. The plan failed to address these unpredictable and unscheduled needs in the overnight hours. Overnight logs provided indicated the patient requires assistance with toileting, personal hygiene, transfer toilet, and ambulation in the overnight hours at least every 3 hours which would not allow a live-in PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Assistant (PCA) Services: Continuous Care, Split-Shift Services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical Spine Disc Herniation. 
Treatment: Code 72141, magnetic resonance imaging (MRI), cervical spine without contrast. 

The insurer denied coverage for code 72141, magnetic resonance imaging (MRI), cervical spine without contrast. 

The denial is overturned. 

This is the case of an adult female. Per the appeal letter from Orthopedic Surgeon, the patient has a history of cervical spine disc herniation that was managed conservatively. She has bilateral upper extremity radiculopathy with worsened symptoms. Magnetic resonance imaging (MRI) is urgently needed. 

MRI is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed. 

The performance of the MRI should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary. 

The letter of appeal submitted by treating physician reports a worsening of condition with concern for spinal cord compression. The physician reports a course of conservative treatment had been provided.  Decisions with regard to further management will depend upon the diagnostic study. ie. Possible surgery versus injection. It would be important to define pathology in the presence of "worsening of condition". 

The request for "urgent" should be taken into consideration. 

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

Code 72141, magnetic resonance imaging (MRI), cervical spine without contrast is considered medically necessary for this patient. 

Based upon clinical description by treating physician, the MRI would be appropriate and necessary at this time. 

The insurer's denial of coverage for code 72141, magnetic resonance imaging (MRI), cervical spine without contrast is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis. 
Treatment: Remicade 10 mg/kg every 4 weeks. 

The insurer denied the Remicade 10 mg/kg every 4 weeks. 
The denial is overturned. 

The patient is a female with moderate to severe ulcerative colitis. She has failed treatment with Remicade 5 mg/kg (milligrams per kilogram) every 8 weeks and 10 mg/kg (milligrams per kilogram) every 8 weeks, with low serum drug levels and ongoing symptoms. Her provider is requesting Remicade 10 mg/kg (milligrams per kilogram) every 4 weeks. 

Yes, the Remicade 10 mg/kg(milligrams per kilogram) every 4 weeks is medically necessary. 

Medical literature supports dose intensification of biologics in patients with UC (ulcerative colitis) who fail treatment with FDA (United States Food and Drug Administration)-approved dosing. Over 25% of patients with UC (ulcerative colitis) treated with biologics require dose intensification. Remicade has been found to be safe and effective at doses as high as 20 mg/kg (milligrams per kilogram) every 4 weeks.

Therefore, as this patient lost response to Remicade 5 mg/kg (milligrams per kilogram) every 8 weeks, and 10 mg/kg (milligrams per kilogram) every 8 weeks, with low serum drug levels, the requested Remicade 10 mg/kg (milligrams per kilogram) every 4 weeks is supported by current peer-reviewed medical literature, clinical practice guidelines, and is standard of care, and therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hallux valgus (acquired), left foot osteopenia

Treatment: foot surgery (procedure code 28299)

The insurer is denied coverage for foot surgery (procedure code 28299)

The denial is overturned. 

This female patient has a history of hallux valgus (acquired), left foot osteopenia

The consent again documents that the patient went thru an extensive course of conservative care without relief prior to undergoing the procedure.  The double osteotomy performed has been denied as not medically necessary. A review of the current literature reveals that hallux valgus surgery improves the quality of life for patients1, and in the case of this patient she clearly outdid all conservative measures prior to undergoing surgery for a deformity that was causing her 7/10 pain and inability to perform her daily activities. One study out of Japan surveyed 116 subjects and found that the quality of life for patients who were untreated and symptomatic, as in the case of this patient prior to surgery, was lower than that of the general population.

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

The carrier's denial of coverage for the foot surgery (procedure code 28299) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Hearing Loss In One Ear. 
Treatment: Surgery (Cochlear Implant) (69930 and L8614). 

The insurer denied the Surgery (Cochlear Implant) (69930 and L8614). 
The denial is overturned. 

The patient is a female with unilateral severe to profound sensorineural hearing loss after trauma.  Other alternatives of Bone-Anchored Hearing Aid (BAHA) and Contralateral Routing of Sound (CROS) hearing aid were considered.  Computed tomography (CT) shows anatomical acceptability of a cochlear implant. 

Yes, the proposed Cochlear implant is medically necessary. 

The medical literature supports the medical necessity of Cochlear implantation as the superior method of improved hearing in patients with single sided deafness versus other modalities that transfer sound to the single hearing ear.  Speech processing and discrimination, an absence of the shadow effect, sound localization and ability to function in a complex sound environment are improved with cochlear implantation. 

Cochlear implantation is a superior modality of correcting single sided deafness as described above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Supraventricular Tachycardia

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

The patient presented to the hospital complaining of palpitations and lightheadedness.  She was transported to the hospital via ambulance. Paramedics noted narrow complex tachycardia at a rate of 200 bpm (beats per minute).  She was treated with adenosine and tachycardia terminated. Upon arrival to the Emergency Department (ED) she was again noted to have palpitations and narrow complex tachycardia that again required adenosine treatment prior to termination. On examination, vital signs were stable, pulse 80 and blood pressure (BP) 122/70.  Physical examination revealed no abnormality.  Electrocardiogram (ECG) revealed sinus rhythm with a short PR (interval on ECG) interval and pre-excitation.   Serum blood testing revealed an elevated troponin level (0.45ng/ml [nanogram per milliliter]). The patient was admitted for observation and treatment. Echocardiogram revealed left ventricular ejection fraction (LVEF) of 50% [percent] without significant valvular abnormalities.  She was transferred to a tertiary care center for electrophysiologic study and ablation.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with narrow complex tachycardia at a rate of 200.  Tachycardia recurred following treatment with adenosine. ECG while in normal sinus rhythm revealed a short PR interval and pre-excitation consistent with Wolff Parkinson White syndrome. Such patients may be at risk for sudden cardiac death and require additional evaluation and risk stratification for rapid conduction down an accessory pathway. (Reference 1) 
The patient also had an elevated troponin level, a known predictor for hospital admission. (Reference 2, 3). 

Given recurrent symptomatic tachyarrhythmia and pre-excitation on ECG, inpatient hospital admission was medically necessary. This patient could not have been managed at a lower level of care. 

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.