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

Diagnosis: Plantar fasciitis and limb length discrepancy
Treatment: Durable Medical Equipment (DME) - Custom Insoles (L3000 X 2)
The insurer denied coverage for Durable Medical Equipment (DME) - Custom Insoles (L3000 X 2)
The denial is overturned

The patient is a female who has a history of plantar fasciitis and limb length discrepancy, per available medical records. The patient had tried over the counter orthotics, Motrin, stretching, along with rest and ice with no relief, thereby prompting the request for custom orthotics with a high medial flange and forefoot posting, by her Podiatrist. Per the visit note, the patient was also holding the foot in a varus position and all neurological causes had been ruled out. 

A review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, there is no optimal answer when it comes to specific orthotic therapy for plantar fasciitis. (1,2) While some patients may benefit from over the counter orthotics, others may get no better without the use of custom orthotics. In the case of this patient, it is clear from the medical records made available that use of over the counter orthotics did not improve the plantar fasciitis. 

Up to Date notes the difficulty in treating plantar fasciitis and in their summary concludes: "In patients in whom the treatments above have not produced sufficient improvement, we occasionally prescribe molded shoe inserts (orthotics) or immobilization in a cushioned walking boot (see 'Initial therapy' above). We do not use other interventions such as extracorporeal shock wave therapy (ESWT) and autologous whole blood or platelet-rich plasma injections, which are costly and of unproven benefit." 

Given the available literature on this topic and this patient's history, in this reviewer's expert opinion, it is best that the orthotics are approved, so that the patient can get the treatment she needs to resolve her plantar fasciitis.

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

The insurer's denial of coverage for Durable Medical Equipment (DME) - Custom Insoles (L3000 X 2) is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic screening.
Treatment: Horizon 274 panel, code 81479 (Unlisted molecular pathology procedure). 
The insurer denied coverage for Horizon 274 panel, code 81479 (Unlisted molecular pathology procedure). 
The denial is upheld. 

This is a male patient with no documented history who underwent genetic screening carrier testing for 274 genetic conditions. His wife was pregnant and was found to be a carrier of Mitochondrial Complex Deficiency. He was found to be a carrier for congenital Amegakaryocytic Thrombocytopenia, Familial Hyperinsulinism, and Familial Mediterranean Fever.  

As per the American College of Obstetricians and Gynecologists (ACOG), testing of the male partner is only needed if his female partner tests positive for a specific medical condition and he should only be tested for that condition. This patient's partner tested positive for Mitochondrial Complex, so the patient should only be tested for this condition as the results of the extensive carrier screening will have no effect on this patient's or his spouse's management.

So in summary, the Current Procedural Terminology (CPT) code 81479, genetic testing for 274 conditions was not medically necessary because there is no proof that these tests will lead to an improvement in health outcome.

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

The insurer's denial of coverage for Horizon 274 panel, code 81479 (Unlisted molecular pathology procedure) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out Seizure.
Treatment: Inpatient stay.
The insurer denied an inpatient stay. 
The health plan's determination is upheld. 

The patient is a male infant that was referred by his pediatrician to the emergency department (ED) with two-day history of three brief spontaneously resolving staring spells. During the spells, he was not responsive to his parents, but he immediately returned to baseline level of activity. The family denied fevers or other constitutional symptoms, but reported a strong family history of epilepsy in the father's family. Vital signs included temperature 98.4, heart rate 130, respiratory rate 36, and 98% saturation in room air. Examination was unremarkable. Head ultrasound was performed with no evidence of periventricular leukomalacia, germinal matrix hemorrhage, or structural abnormalities. Laboratory evaluation, including viral panel, metabolic panel, and complete blood count, was unremarkable except for mildly elevated transaminases (aspartate aminotransferase (AST) 59, alanine aminotransferase (ALT) 76). He remained stable in the ED with no further spells. He was admitted for evaluation of new-onset seizures. 

The Acute inpatient admission was not medically necessary for this infant. He could have been safely managed at a lower level of care.
The differential diagnosis of first-time afebrile seizure-like activity is quite broad, and includes head trauma, abuse, toxic ingestion (intentional or accidental), infection, elevated intracranial pressure, and anatomic abnormalities. Initial evaluation must include a complete history and comprehensive physical examination to identify possible life-threatening causes of seizures. Characterization of the type of seizure is also important, differentiating between febrile and afebrile, focal and generalized. Investigation includes laboratory studies and imaging. In young infants, ultrasound is sufficient to identify structural abnormalities and hemorrhage. Magnetic resonance imaging (MRI) may be indicated later to further evaluate grey-white matter differentiation and intracranial structures. Electroencephalogram, with or without concurrent video, is useful but a negative study does not rule out seizure activity. Other laboratory testing or lumbar puncture are led by the patient's presentation and concurrent symptoms. Medication may or may not be prescribed.
In this infant's case, he had three brief self-resolved episodes of staring with immediate return to baseline. Concern for seizure was increased because of strong family history of epilepsy. While it was not inappropriate to monitor the infant in the hospital, particularly because of his young age, he was overall hemodynamically and neurologically stable. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Pain.
Treatment: Methadone Tablets 10 milligrams (mg) for a quantity of 180 tablets per month (Pre-Service).
The insurer denied the Methadone Tablets 10 milligrams (mg) for a quantity of 180 tablets per month (Pre-Service).
The denial is overturned.

The patient is a male with chronic neuropathic pain who has been on Methadone for several years.  He is taking 180 pills (60 mg a day) for a 30 day supply. The dose has been weaned down over the years.

Yes, the proposed treatment is medically necessary.

The patient is a male with chronic neuropathic pain who has been on Methadone for several years.  He has been stable on this dose for some time.  He is taking 180 pills (60 mg a day) for a 30 day supply. The dose has been weaned down over the years to this amount. The patient is seen by a pain management provider regularly. He has been warned and is monitored for side effects and complications of chronic opiates. The pain treatment plan is re-evaluated at each follow up.  There are no signs of aberrancy or red flags.  There is no ceiling on opiates, and the patient has been stable on this dose and this is a continuation of therapy. The patient's provider is open to further weaning the medication slowly.  The dose is within common dosing regimens.  Given the above, the requested quantity is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: End-stage renal disease. 
Treatment: Vascular Surgery (upper extremity A-V fistula created for vascular access using wavelinQ device) (37799). 

The insurer denied the Vascular Surgery (upper extremity A-V fistula created for vascular access using wavelinQ device) (37799). 

The denial is upheld. 

The patient is a male. He was approaching ESRD (end-stage renal disease) and need for hemodialysis. This patient had placement of an Endovascular Arteriovenous Fistula (EndoAVF) using the WavelinQ system. This is a review of that date of service. 

No, the health plan should not cover the Vascular Surgery (37799). 

This technology at this time is considered as unproven/experimental/investigational. 

No, the Vascular Surgery (37799) is not likely to be more beneficial.
As per Woo K, et al. [1], "However, evolving therapies have allowed the creation of arteriovenous connections using endovascular techniques [2-7]. Using this approach, specially designed catheters are used to join the walls of the antecubital vessels to create the fistula. Two technologies approved for use in the United States are available for percutaneous arteriovenous fistula (pAVF) creation; these techniques are only just beginning to be used on a larger scale. While initial clinical success rates in pivotal trials has been high, studies with more patients, longer follow-up, and controlled comparisons with surgical access creation are needed. Variables for access evaluation and planning, as well as follow-up, maintenance, and care of percutaneous AV (arteriovenous) fistulas, are being actively investigated." 

Specifically, as per Jones R, et al. [2], "EndoAVF [endovascular arteriovenous fistula] has the potential to provide an extended lifeline requiring much lower maintenance and morbidity than the traditional AV [arteriovenous] access in end-stage renal failure patients, but the effect of the endoAVF [endovascular arteriovenous fistula] on current vascular access paradigms will depend on the continued success and development of this technology." 

However, of special concern is as stated by Jones R, et al. [2], "To date, there are very few reports of endoAVF [endovascular arteriovenous fistula] patients requiring secondary surgical intervention, but their complex anatomy akin to a post-traumatic AVF [arteriovenous fistula] could potentially make them challenging to ligate or modify should this be required (either surgically or with embolization). This adds to the overall unproven nature of these endoAVF [endovascular arteriovenous fistula] access procedures." 

While the procedure is considered as safe and promising, it was not performed under controlled research setting, and it does not use a specific research protocol.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: End-stage renal disease. 
Treatment: Vascular Surgery (upper extremity A-V fistula created for vascular access using wavelinQ device) (37799). 

The insurer denied the Vascular Surgery (upper extremity A-V fistula created for vascular access using wavelinQ device) (37799). 
 
The denial is overturned. 

The patient is a male. He underwent creation of an endovascular arteriovenous fistula (AVF) using the WavelinQ system. The patient has end-stage renal failure and impending need for hemodialysis. The procedure was uneventful. 

The surgery was denied on the basis that "[t]he medical literature does not show that there is sufficient clinical evidence for efficacy and safety for use." 

Yes, the health plan should cover the Vascular Surgery (37799). 

The patient is a male. He underwent creation of an endovascular arteriovenous fistula (AVF) using the WavelinQ system. The patient has end-stage renal failure and impending need for hemodialysis. The procedure was uneventful. 

WavelinQ is an FDA (United State Food and Drug Administration)-approved endovascular procedure that uses radio frequency (RF) to form a fistula between a vein and artery. Early data [1-3] show that WavelinQ is a safe and effective procedure. There are not yet definitive data to show whether WavelinQ is better or worse than alternative means of AVF (arteriovenous fistula) creation. However, early data from a single site [2] show that WavelinQ may be superior to surgical AVF (arteriovenous fistula) creation. 

AVFs (arteriovenous fistulas) are widely accepted as the best method of long-term hemodialysis, but functional maturation rates of traditional surgical AVFs (arteriovenous fistula) are only around 70%. For this reason, there is a need for identifying better methods of AVF (arteriovenous fistula) creation. It is not yet clear that WavelinQ is superior to surgical AVFs, but the early data support its role as a viable alternative. Additional clinical experience will eventually determine the role of this new procedure. 

The procedure is new, but it should not be considered experimental or investigational. Current data demonstrate that it is safe and at least as effective as surgical AVF (arteriovenous fistula) creation. 

Yes, the Vascular Surgery (37799) is likely to be more beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: End-stage renal disease. 
Treatment: Vascular Surgery (upper extremity A-V fistula created for vascular access using wavelinQ device) (37799). 

The insurer denied the Vascular Surgery (upper extremity A-V fistula created for vascular access using wavelinQ device) (37799). 

The denial is upheld. 

The patient is a male right-handed with history of hypertension and renal insufficiency. Patient underwent endovascular intervention to create AV (arteriovenous) fistula. 

No, the health plan should not cover the Vascular Surgery (37799). 

The patient is a male right-handed with history of hypertension and renal insufficiency.  The patient is being evaluated for dialysis access placement based on history and physical note. The patient has palpable brachial and radial and ulnar pulses. 

The patient underwent endovascular repair/creation of the left upper extremity for creation of AV (arteriovenous) fistula with wave link device and coil embolization. 

There has been no prospective, randomized studies to compare this procedure directly with the creation of AV (arteriovenous) fistula or AV (arteriovenous) graft regarding long-term patency, complications, and re-intervention rate as well as efficacy of the procedure. 

This procedure is not standard of care and not accepted by the vascular community at this point. 

No, the Vascular Surgery (37799) is not likely to be more beneficial. 

There has been no prospective, randomized study to compare this procedure directly with the creation of AV (arteriovenous) fistula or AV (arteriovenous) graft regarding long-term patency, complications, and re-intervention rate and efficacy of the procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oversized Breasts
Treatment: Reduction Mammaplasty
The insurer denied a reduction mammaplasty. The health plan's determination is overturned.

This female complains of back, neck and shoulder pain due to her large breasts. Photos show a female with large breasts. Physical therapy and support bras have not improved her symptoms. She has no co-morbid conditions that can explain her symptoms. Her surgeon recommends bilateral breast reduction with the removal of 800 grams of tissue total. This is the subject under review.

Reduction Mammaplasty [Removal of Tissue from Breast] is medically necessary for this patient. She has the classic symptoms for macromastia, and medical treatments for over one year have not improved her symptoms. Neurology and orthopedics have ruled out other causes for her symptoms. Her surgeon plans a reduction of at least 800 grams of tissue total. Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. 

This patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Photos show that she has oversized breasts. Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and hundreds of peer-reviewed studies confirm the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mixed mechanism glaucoma.

Treatment: Cosopt (dorzolamide- timolol).

The insurer denied coverage for Cosopt (dorzolamide- timolol).

The denial is overturned. 

This is a male patient with a diagnosis of mixed mechanism glaucoma in both eyes. The patient's most recent visual acuities were 20/70 in the right eye (OD) and 20/100 in the left eye (OS). Intraocular pressures were 18 millimeters of mercury (mmHg) in both eyes (OU). Diagnosis of mixed mechanism glaucoma was noted with benzalkonium chloride (BAK)-related ocular surface disease from glaucoma drops. With increased intraocular pressures, the patient was to continue Zioptan and start preservative-free Cosopt.  

The patient's intraocular pressures were not controlled with Zioptan (a preservative-free drop), so preservative-free Cosopt is medically necessary. BAK toxicity is a known adverse effect of glaucoma drops, and preservative-free drops are standard of care for patients with glaucoma who are allergic to standard glaucoma drops with BAK preservatives.

The request for preservative-free Cosopt is medically necessary for this patient. He has tried Latanoprost and dorzolamide-timolol, but developed BAK-related (chemical-related) ocular surface disease due to preservatives in the drops. The other formulary alternatives are contraindicated because they also contain preservatives that would cause ocular surface disease/chemical conjunctivitis. The patient's intraocular pressures were not controlled with Zioptan alone (a preservative-free drop). Thus, preservative-free Cosopt is medically necessary for this patient to control intraocular pressure and prevent vision loss from glaucoma.

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient. The patient has an allergic reaction to glaucoma drops that contain BAK preservatives. Thus, the formulary alternatives are contraindicated for this patient and preservative-free Cosopt is medically necessary.

The insurer's denial of coverage for Cosopt (dorzolamide- timolol) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right flank pain
Treatment: Inpatient stay

The insurer denied the inpatient stay. The health plan's determination is upheld.

This case involves a woman with no past medical history who presented to the hospital with severe right flank pain with associated vomiting. Symptoms started suddenly, with a sharp stabbing right flank pain. The symptoms were intermittent in nature. She denies any fevers or chills. The patient had a dental extraction procedure the previous day and was taking clindamycin and Percocet. She was seen in the emergency department, where a computed tomography (CT) scan of the abdomen pelvis revealed a 9 millimeter (mm) calculus in the proximal right UPJ (Ureteropelvic Junction) with mild right hydronephrosis. The patient was given pain medications and a dose of intravenous (IV) ceftriaxone in the emergency department and admitted to the hospital. Vital signs on arrival included a normal temperature, heart rate of 82, blood pressure 133/59. On exam, there were no major abnormalities except for right flank tenderness. Labs revealed normal blood urea nitrogen (BUN) and creatinine, a glucose of 83, and stable electrolytes. The white blood cell count was 8.8, with a hemoglobin of 12.6. Urinalysis revealed numerous epithelial cells, microscopic hematuria, and 191 white blood cells. Chest x-ray was normal. The patient was admitted to the hospital with an obstructing kidney stone and possibly a urinary tract infection (UTI). 

The inpatient admission is not medically necessary for this patient.

This is a case of renal colic caused by an obstructing stone that required urologic decompression. These types of presentations are typically evaluated and treated at a lower level of care, controlling symptoms until a urologic procedure can be performed. Once the decompression is completed, typically, the patient is released home with a short course of antibiotics given the presence of stent and outpatient urologic follow-up within a week. There is no evidence of complicating conditions in this presentation. There is no clear evidence of concurrent urinary tract infection or pyelonephritis, simply based on the urinalysis. The patient has no chronic medical problems and is not suffering from severe dysfunction of the kidneys due to the obstructing stone. The urologic procedure was uncomplicated. There is no evidence of urinary retention. There is no evidence of systemic illness, such as sepsis or pyelonephritis, which cannot be managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Mental Health
Pharmacy/prescription drug

Diagnosis: attention deficit hyperactivity disorder (ADHD)
Treatment: Vyvanse
The insurer denied Vyvanse. The health plan's determination is overturned. 

The patient is a man diagnosed with attention deficit hyperactivity disorder. Treatment with Vyvanse is the subject of this review. The patient has been on Vyvanse for years.

A formulary exception is indicated.
There is documentation that the patient has tried and failed dextroamphetamine/amphetamine, methylphenidate ER (extended release) and Focalin extended release (XR). Per the provider, all of these drugs have been ineffective. The only formulary alternative that the patient has not tried and failed is atomoxetine, which is not a stimulant, but a noradrenaline re-uptake inhibitor. As such, this would require the patient to change from a stimulant to a non-stimulant drug. This drug would likely not be as effective for this reason.
As the patient has tried and failed 3 of the 4 available formulary alternatives and the only drug not tried and failed is likely to be ineffective, coverage of Vyvanse is medically appropriate. Furthermore, the patient has been stable on Vyvanse for years.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peyronie's disease.
Treatment: Xiaflex.
The insurer denied the Xiaflex.
The determination is overturned.

The patient has a diagnosis of Peyronie's disease. The records document a curvature of 30-40 degrees and a palpable plaque. He is noted to have stable disease. He does not have erectile dysfunction (ED). Xiaflex treatments have been recommended. At issue is the medical necessity of Xiaflex.
The Xiaflex is medically necessary for this patient. The patient has intact erectile function. The Food and Drug Administration (FDA) Prescribing Information is as follows: "The treatment of adult men with Peyronie's disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy (1)."  The FDA criteria for coverage were met. Criteria regarding degree of curvature, palpable plaque and stability of disease were met. The records document a curvature of 30-40 degrees and a palpable plaque. Therefore, the Xiaflex is medically necessary.