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

Diagnosis:  Palpitations.
Treatment:  Wearable ECG (electrocardiogram) recording device (CPT [current procedural terminology] 93228/93229).

The insurer denied coverage for a wearable ECG recording device (CPT 93228/93229).  The denial is overturned.

The patient complains of recurrent palpitations. A physical examination was within normal limits. Exercise stress testing revealed normal sinus rhythm with occasional VPCs, (Ventricular premature complexes), and the patient reached the maximal predicted heart rate. In order to correlate symptoms with rhythm abnormality, a mobile ECG recorder was ordered.

A wearable ECG recording device (CPT 93228/93229) is medically necessary.  This patient had a history of episodic palpitations. This patient underwent exercise stress testing and ventricular ectopic beats were noted. Correlating patient symptoms with electrocardiographic tracings is important and is medically necessary. Mobile telemetry monitoring is an important diagnostic tool for the detection of atrial fibrillation, risk stratification or evaluation of arrhythmia symptoms. (1) In this case such a device would allow a physician to determine whether symptoms are due to atrial fibrillation or an alternative arrhythmia that would require treatment. Heart Rhythm Society guidelines note that accurate and timely diagnosis is critical to direct therapy that can make an impact on patient care and healthcare utilization. (2) In conclusion, wearable mobile cardiac telemetry monitoring was medically necessary in this case.

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 wearable recording device (CPT codes 93228 and 93229) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with sickle cell and recently diagnosed common bile duct (CBD) stone.  He presented with right upper quadrant (RUQ) pain  as well as vomiting and diarrhea for approximately six days. Recent imaging revealed a common bile duct stone. He was admitted for endoscopic retrograde cholangiopancreatography (ERCP). Bilirubin was elevated at 14. There was no evidence of hemodynamic instability, intractable vomiting or sepsis. 

Endoscopic retrograde cholangiopancreatography with sphincterotomy was performed at which time it was felt that he had passed a common bile duct stone. The patient's diet was advanced, pain was improved, there was no further vomiting and he was discharged.

No, the proposed inpatient hospital admission was not medically necessary.

There was no evidence of hemodynamic instability, sepsis, intractable vomiting, severe pain or biliary obstruction.  Endoscopic retrograde cholangiopancreatography can be performed on an outpatient basis, and an acute inpatient hospital stay is not medically necessary.  Therefore, the inpatient hospital stay for this patient was not medically necessary.

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

As acute inpatient stay was not medically necessary; the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying the acute inpatient hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient admission.

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

The patient is a male without a reported seizure history but was drinking three shots of liquor daily prior to stopping recently, who was brought by ambulance after being found unresponsive. He was noted to have nausea, vomiting and dizziness prior to passing out. He had a seizure-like episode in the emergency room and was given lorazepam. 

The patient was admitted for further workup as well as neurologic consultation. Workup was significant for transaminitis. The patient was noted to be back to baseline. Neurology recommended electroencephalogram (EEG) and magnetic resonance image (MRI) as an outpatient. The hospital admission was denied by the plan for not meeting criteria.

No, the proposed inpatient hospital admission was not medically necessary.

The patient had a one time witnessed seizure-like episode, was back to neurologic baseline after the seizure and did not have any more seizures. Milliman Care Guidelines (MCG) recommended inpatient admission for seizures that fail to respond to first line agents or lack of return to baseline concerning for status epilepticus. This patient was back to baseline, did not have any other seizures and could have been placed in observation status.

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

The patient did not meet Milliman Care Guidelines for inpatient admission and care could have been done on an observation basis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19 pneumonitis
Treatment is an inpatient admission 	
The insurer denied coverage for an inpatient admission 
The denial is upheld

This is a patient with a past medical history significant for hypertension and asthma who presented to the emergency department with complaints of fever, headaches, chills, and cough. 

Vitals on presentation included: Temperature 102.8 F (Fahrenheit), Blood Pressure 165/104, Pulse 122, Respiratory Rate, oxygen (O2) saturation 98% on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 8.2, Hgb (hemoglobin)-13.4, Hct (hematocrit) -41.6, creatinine-0.81, glucose-96, d-dimer (protein fragment) -0.55. The venous Doppler was negative for deep vein thrombosis (DVT). Chest x-rays (CXR) were negative.

The patient was admitted to the hospital for COVD-19 pneumonitis. Infectious Diseases consulted and the patient was treated with intravenous (IV) monoclonal antibody therapy (Bebtelovimab), IV dexamethasone, and intravenous Remdesivir. The patient remained afebrile and hemodynamically stable, and improved clinically. She was discharged to continue outpatient management. 

Although COVID treatment and management guidelines continue to evolve, the decision to hospitalize patients with a COVID infection is typically based on presence of severe dyspnea (dyspnea at rest and interfering with the ability to speak in complete sentences), oxygen saturation on room air <= 90% (regardless of severity of dyspnea), alterations in mentation (i.e., confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Similarly, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of <94 percent on room air, respiratory rate of >30 breaths/minute, PaO2/FiO2 <300 mmHg (millimeters of mercury), or lung infiltrates >50 percent. According to the medical records, this patient was "speaking in full sentences without shortness of breath on room air." Emergency department notes describe- "patient resting comfortably on stretcher." Furthermore, her O2 saturation was 98% on room air and the CXR was normal. The patient met the criteria for an observation level of management. 

Based on above finding, prior determination of denial of inpatient hospitalization is upheld. 

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

Diagnosis: Esophagitis and gastritis

Treatment: Gastric testing (procedure code 43239)

The insurer denied coverage for gastric testing (procedure code 43239)

The denial is upheld

The patient was having abdominal pain. A progress note was submitted. The medication list does not contain a proton pump inhibitor (PPI) or histamine 2 (H2) blocker. At that visit Omeprazole was started. An endoscopy was performed, and esophagitis and gastritis were found. The biopsies were negative for Barrett's esophagus and Helicobacter pylori (H. pylori).  

Milliman Care Guideline (MCG) ACG: A-0203 lists indications for Upper Gastrointestinal (GI) Endoscopy. Dyspepsia is an indication for treatment if it is associated with an age of 60 or older, failure of medical therapy, presence of a first degree relative with upper gastrointestinal (UGI) cancer, vomiting, or weight loss. Gastroesophageal reflux is also an indication if there is anemia, GI bleeding, a 5-year history of symptoms with other risk factors, or if there was a failure of medical therapy.

This patient did not have a documented failure of medical therapy. The endoscopy was scheduled at the same visit that the Omeprazole was started. There is also no documentation that she was having GI bleeding or that she has had symptoms for over 5 years. Therefore, she did not meet MCG criteria for doing an upper GI endoscopy.

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

The insurer's denial of coverage for gastric testing (procedure code 43239) is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD).
Treatment: Surgical procedure (43284) esophageal sphincter augmentation device around the lower part of the esophagus.
The insurer denied coverage for surgical procedure (43284) esophageal sphincter augmentation device around the lower part of the esophagus.
The denial is overturned.

The patient has a history of gastroesophageal reflux disease (GERD) and has been treated with proton pump inhibitor (PPI) therapy. He underwent a workup including endoscopy, esophageal manometry, upper gastrointestinal (GI) series, and Bravo pH (potential for hydrogen) testing. He was found to have a small hiatus hernia and Grade C (erosion(s) extending over mucosal folds, but over less than three-quarters of the circumference) reflux esophagitis. The DeMeester score was 31. 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the LINX Reflux Management System in March 2017. With regards to safety, the conclusion was that long-term follow up supports the Food and Drug Administration's (FDA's) conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following LINX. The long-term follow-up data demonstrates that the LINX Reflux Management System is effective in the management of GERD.

The scientific peer-reviewed literature supports the use of the LINX system as resulting in improvements in health outcomes. The procedure has FDA approval. There are several procedures available for the treatment of GERD, but the LINX system has been shown to be safe and effective. The LINX Reflux Management System has been shown to be beneficial in patients with chronic reflux symptoms who have not responded adequately to PPI therapy.

The requested procedure is likely to be more beneficial than any other existing standard health service.

The carrier's denial of surgical procedure (43284) esophageal sphincter augmentation device around the lower part of the esophagus is overturned.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Broken amalgam filling, cavities
Treatment: Tooth Colored Crown for Teeth #s 3, 5, 7, 8, 9, and 10
Post and Hard Material Under Cap for Tooth #3
The insurer denied the Tooth Colored Crown for Teeth #s 3, 5, 7, 8, 9, and 10
Post and Hard Material Under Cap for Tooth #3
The denial is overturned, in part.

The patient is a female requesting crowns on teeth #'s 3, 5, 7, 8, 9 and 10. A cast post and core is also requested for tooth #3. 

The prior denial was due to the teeth not meeting requirements for treatments.

Yes, in part; the proposed treatment for teeth #'s 5 and 7 is medically necessary. However, no in part; the proposed treatment for teeth #'s 3, 8, 9 and 10, the proposed treatment is not medically necessary.
Tooth #5 has had a root canal procedure done to it and has a broken amalgam filling. There is not much solid tooth structure left. This tooth can only be properly restored with a crown.

Tooth #7 has two large cavities in it. Upon removal of all the decay, there will not be much solid tooth structure left. A crown is the only way to properly restore the tooth.

With the x-rays provided, teeth #'s 3, 8, 9 and 10 do not show any need for restorations. No decay is seen in the provided x-rays.  Therefore, no crowns (or cast post and core for #3) are needed.

Yes, in part; the health plan did act reasonably, with sound medical judgment and in the best interest of the patient for teeth #'s 3, 8, 9 and 10 as the proposed treatment was not medically necessary.  However, no, in part; the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient for teeth #'s 5 and 7 as the proposed treatment was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart failure, Shortness of breath. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history (PMH) of alcohol dependence, anxiety, coronary artery disease (CAD), liver failure, and severe heart failure with reduced ejection fraction (HFrEF) with ejection fraction (EF) 10% status/post (s/p) implanted cardiac defibrillator who was admitted with complaints of (c/o) shortness of breath associated with increased lower extremity (LE) swelling and orthopnea. Vital signs were notable for a blood pressure (BP) of 92/62. The physical exam was notable for bilateral lower extremity (LE) edema plus (+) 5, speaking full sentences without distress. Lab work was notable for brain (or B-type) natriuretic peptide (BNP) 2470, sodium (Na) 127, magnesium (Mg) 1.2. Imaging studies, a chest x-ray (CXR) showed no acute disease. An electrocardiogram (EKG) showed no significant segment (ST) elevations or depressions. The patient was diagnosed with acute on chronic heart failure and treated with intravenous (IV) diuresis, electrolyte repletion, acute coronary syndrome (ACS) rule out (r/o), and medication optimization. The patient was discharged against medical advice. At issue is the medical necessity of an inpatient level of care. 

No, the admission was not medically necessary at an acute inpatient level of care. This patient with a known history of heart failure presented to the emergency department (ED) with c/o shortness of breath associated with increased LE swelling and orthopnea. The patient was not in acute distress and was hemodynamically stable. Additionally, the patient was not severely compromised, did not have elevated blood urea nitrogen, symptomatic low admission systolic blood pressure, significantly elevated creatinine, severe hyponatremia, cardiac ischemia, airway instability, cardiac arrhythmias requiring continuous intravenous (IV) intervention, or inadequate systemic perfusion, nor did the patient require vasodilator therapy. Finally, the patient's Ottawa Heart Failure Risk Scale (OHFRS)-Heart Failure Risk Score was 0 and the Get With The Guidelines (GWTG)-Heart Failure Risk Score was 41, not consistent with high-risk for serious adverse events. Overall, this patient was monitored, received IV diuresis and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder - right temporal lobe hemorrhage. 
Treatment: Inpatient Hospital. 
The insurer denied continued skilled nursing stay. 
The denial is upheld.

The patient is a male with a seizure disorder, treated to baseline with Keppra, poorly controlled diabetes mellitus with glycated hemoglobin (A1c) of 13, and hyperlipidemia, who suffered an intraparenchymal brain hemorrhage and status epilepticus, for which he was admitted to the hospital. The patient was intubated, and required mechanical ventilation, nicardipine drip, and Keppra reload. The computed tomography (CT) scan of the head demonstrated a right temporal lobe hemorrhage. His blood pressure was stabilized, and he was eventually extubated and stabilized. He was assessed at the medical facility by Physical and Occupational Therapy. He was deemed appropriate for subacute rehab, where he was transferred.

The question is whether the patient required additional skilled nursing facility stay.

The health plan's determination is upheld.

The patient actively participated in the rehabilitation process, and he showed a steady improvement during this time frame. The patient suffered a hemorrhagic stroke without focal deficits but exhibited gross weakness in all 4 extremities and some lightheadedness. By the end of the 21 days, the patient was ambulating 75 feet with supervision, performing transfers with supervision, was no longer lightheaded, had stable blood pressure, improved control of blood glucose values, and overall stability of the chronic medical problems. The goals of the skilled nursing facility stay were accomplished.

The provided documentation notes that the patient had appropriate progression in his physical activity, and improvement in activities of daily living (ADL) ability, by the time of discharge to progress to the next level of care.

The patient can ambulate 75 feet, per the last documented note, and only requires supervised transfers. Per activities of daily living scoring calculator, the patient falls between low-level ADL acuity and independent level ADL acuity. The patient is transitioning from subacute rehab into his sister's apartment, which has an elevator. A distance of 75 feet is adequate for the patient to safely traverse the distance from the living room to the kitchen and the bedroom. The patient is awake, alert, and oriented x 3, with a benign exam. The pain in the left shoulder appears chronic and can be assessed further in a lower level of care setting.

Based on the documentation, there are no clinical indications for ongoing skilled nursing facility stay.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis (MS)
Treatment: Tecfidera
The insurer denied coverage for Tecfidera.
The denial is upheld.

The patient was seen for a follow up regarding his multiple sclerosis (MS). The provider noted that the patient had abdominal pain which resolved after stopping Vumerity. He reported that the patient had no side effects from Tecfidera. He noted that the plan was to either go back to Tecfidera or to try Aubagio. 

"The conventional approach to treating MS includes the use of medications to control disease activity and some symptoms and rehabilitation interventions to alleviate symptoms resulting from damage to the CNS (central nervous system). Medications that help decrease MS disease activity are referred to as disease-modifying agents, or DMTs. Most of the DMTs are approved by the U.S. Food and Drug Administration (FDA) for relapsing forms of MS. These DMTs can broadly be broken down into route of delivery, including injectable medications, oral medications, and infusions. Compared with a placebo, these medications decrease the relapse rate by 30% [percent] to 67%, decrease new lesion formation in the brain as detected by MRI (magnetic resonance imaging) and decrease the risk of developing a permanent neurological disability." (Lane, M., & Yadav, V., 2020)

"Nine classes of disease-modifying therapies (DMTs), with varying mechanisms of action and routes of administration, are available for relapsing-remitting MS, defined as relapses at onset with stable neurologic disability between episodes, and secondary progressive MS with activity, defined as steadily increasing neurologic disability following a relapsing course with evidence of ongoing inflammatory activity. These drugs include interferons, glatiramer acetate, teriflunomide, sphingosine 1-phosphate receptor modulators, fumarates, cladribine, and 3 types of monoclonal antibodies. One additional DMT, ocrelizumab, is approved for primary progressive MS. (McGinley, M. P., et al. 2021)

The requested drug may not be more effective than the formulary drugs. The formulary drugs are likely to be as effective, if not more effective, compared to Tecfidera. The patient is diagnosed with MS. The patient experienced abdominal pain while on Vumerity. This resolved after stopping the medication. The patient did not experience adverse effects while on Tecfidera. As such, the treating provider's plan as stated in the documentation was to either go back to Tecfidera or try Aubagio. The patient was intolerant to Vumerity and to generic Tecfidera and had good disease control on Tecfidera. Based on the patient clinical history the formulary alternatives have not been shown to be ineffective for this patient and are no more likely to cause the patient an adverse reaction than those which may be caused by Tecfidera.
                                               
The insurer's denial of coverage for Formulary Exception for Tecfidera is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder - Cerebral Palsy. 
Treatment: Physical Therapy. 
The insurer denied physical therapy services. 
The denial is upheld.

The patient is a male with a diagnosis of cerebral palsy. Included for review are verbal appeal and also letter from patient's father; therapy notes from Intensive Therapeutics for the time period in question, and invoices from Intensive Therapeutics. The subject under review is the medical necessity for physical therapy services.

The requested physical therapy (PT) health service in question is not medically necessary for this patient. Repeated codes of 97150 (group therapeutic procedures) for an individual date is not appropriate or medically necessary as the code 97150 is independent of time. Given the patient's diagnosis of cerebral palsy it would be expected that patient will have need for many years of physical therapy especially while a developing child. However, each instance of therapy and the type of therapy must be reviewed for medical necessity for patients who have an overall need for therapy. It was medically necessary for patient to have the therapy sessions that were already approved however billing for additional services on the same date is not appropriate or medically necessary.
PT is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice.
Billing multiple units of the same code for an individual date is not reasonable under accepted standards of practice and therefore these sessions are not medically necessary.