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

Diagnosis: Atypical chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient presented to the hospital complaining of chest pain and shortness of breath lasting for thirty minutes.  He had been worked up for similar symptoms over the past several months. Past medical history was significant for aortic aneurysm repair with aortic valve replacement, hypertension, and multiple sclerosis with paraplegia/wheelchair bound status.  Upon arrival, vital signs were stable [BP (blood pressure) 114/78mmHg (millimeters of mercury), Pulse 94 bpm (beats per minute)]. Physical exam revealed flaccid muscle tone in both lower extremities and weakness of the upper extremities.  A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm without ischemic ST (interval on EKG) or T (interval on EKG) wave abnormalities. Serum blood testing revealed no elevation in troponin (7ng/L [nanogram per litre]).

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

This patient presented with atypical chest pain and a past medical history of recent negative ischemia work up for similar symptoms in the months prior to presentation. His pretest probability of coronary artery disease was low (Reference 1).  Utilizing the HEART (history, EKG, age, risk factors, and troponin) score, he was considered low risk (Reference 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 (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 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 (mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. 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 inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paraophthalmic segment aneurysm
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned

The is a patient with a past medical history of gastroesophageal reflux disease and ovarian cyst. Her history of present illness states bilateral paraophthalmic segment aneurysms status post pipeline embolization of left sided aneurysm (on Aspirin and Plavix) who presented for treatment of the right sided aneurysm. After her first embolization, she remained neurologically intact.

She underwent embolization of the cerebral artery. There were no complications. She was admitted to Neuro Surgical ICU (intensive care unit) due to recent brain surgery and was at risk for complications and required close neurologic monitoring. Her exams remained normal. Post-procedure she was started on a heparin infusion and CT (computed tomography) head. The plan was to monitor neuro exam/access site/pulse, head of bed 0 degrees until, bed rest, Tylenol as needed, antiplatelets per Interventional Radiology, Heparin at 400 units/hour, P2Y12 (chemoreceptor) today and tomorrow, systolic blood pressure between 90-140 with hydralazine/labetalol as needed, Lovenox, vital signs every hour with neuro checks and advance diet as tolerated. She underwent a CT of the head, her order was changed to out of bed, discontinue heparin. She had P2Y12 testing that was appropriate. On discharge, she was continued on Aspirin and Plavix.

Records show that she was admitted to inpatient to Neuro ICU after her procedure. She was discharged. Her admitting diagnosis is right paraophthalmic segment aneurysm.

The patient underwent a procedure with a high risk of postoperative injury. She was admitted to Neuro ICU and underwent close monitoring. Her care could not have been provided at a lower level of care per InterQual guidelines for Endovascular Intervention, Intracranial, Endovascular Embolization (1).
The patient was on aspirin and Plavix and underwent intracranial embolization of an aneurysm that necessitated ICU care to include IV (intravenous) heparin, every hour neuro checks and postoperative imaging and lab testing. Her care could not have been provided at a lower level of care given the risk of injury after surgery.

The management of paraophthalmic aneurysms is associated with specific risks. The overall complication rates of these procedures are low; however, cerebral ischemia, intracranial hemorrhage and visual complications must be considered in advance and the patient must be informed of the risks. (2)

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Stelara
The insurer denied coverage for Stelara.
The denial is upheld.

The patient developed ulcerative colitis at an early age. He was initially treated with prednisone and then Remicade. He was switched to Entyvio. He was started on Xeljanz which was then stopped. His physician is now requesting to give Stelara in combination with Entyvio. 

Gastroenterology and Hepatology 2021 Sep;17 (19): 406-414 has an article titled "Efficacy and Safety of Dual Biologic Therapy in Patients with Inflammatory Bowel Disease: A Review of the Literature." The article states that thus far, the data on the efficacy and safety of dual biologic therapy as a treatment for Crohn's disease remains quite limited. The overwhelming majority of the literature consists of case reports. The conclusion was that dual therapy is a potential therapeutic option but that more data was needed before this could be adopted as a treatment approach. A recent article by Baumgart and Le Berre did not mention combining biologics in inflammatory bowel disease. (2) 

This patient has refractory ulcerative colitis and has failed multiple biologic therapies. However, giving dual biologic agents has only been studied on a limited basis. It is not advised by the American College of Gastroenterology guidelines for ulcerative colitis to give the combination of Stelara and Entyvio.

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

The medical necessity for adding Stelara at the outpatient level of care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low testosterone levels and testicular hypofunction
Treatment: testosterone gel 1.62% (percent)
The insurer denied coverage for testosterone gel 1.62%
The denial is upheld.

This is an adult male with past medical history of hypertension, hyperlipidemia, diverticulitis, low testosterone levels and testicular hypofunction. Testosterone level was 313, with reference range being 193-740ng/dl (nanogram per deciliter).  A prior Testosterone (TST) level was 227, with lab reference range 250-110ng/dl. Testosterone gel 1.62% is recommended for this patient. 

The insurer has denied coverage, stating that 2 abnormally low serum TST levels have not been sent to them. The TST levels must be drawn in the early ante meridiem (AM) and must be from 2 different days. They also stated that lab values from the prior 12-24 months were not sent to them. The appeal by the patient is noted and read in detail. To be eligible for coverage of supplement TST for treatment of hypogonadism, the standard of care is to have 2 separate TST levels, drawn in the early morning and on separate occasions, be submitted to substantiate the clinical diagnosis. In this case, one level was 313- within the labs reference normal range, and a prior level was 227, which is below the lab reference range, however by the lab sheet, the TST level was drawn in the late afternoon, not the very early morning, as it should be for maximal accuracy.

Testosterone gel 1.62% is not considered medically necessary for this patient eligibility criteria are not met by submitted labs.

Based on the above, the insurer's denial is upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for testosterone gel 1.62% services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility
Treatment is PGT-A (preimplantation genetic testing for aneuploidies)
The insurer denied coverage for PGT-A.
The denial is upheld.

The patient underwent in vitro fertilization with PGT-A (preimplantation genetic testing for aneuploidies). A euploid embryo was transferred and the patient conceived. 

Embryo aneuploidies may be responsible for implantation failures, miscarriages and affects IVF (in-vitro fertilization) outcomes. A variety of technologies have been implemented to evaluate euploid embryos in IVF treatments, {preimplantation genetic testing for aneuploidies (PGT-A)}. 

According to this strategy, a better embryo selection should increase IVF results. In reality, several issues remain unaddressed including the sampling strategy, involving the test outcomes, and the frequent occurrence of embryo mosaicism, affecting the criteria for selection of supposed viable embryos. Safety issues are in place, including peri-and post-natal consequences of embryo sampling and the epigenetic weaknesses from a prolonged in vitro culture. On the other side, chromosome number mistakes are progressively recognized as physiologic events in the early pre-implantation embryo with many corrective mechanisms in place and their destiny in the post-implantation development is unclear. The diagnosis of embryo aneuploidies in IVF cycles should be considered as a research tool and systematic implementation in clinical practice may appear unjustified. 

ASRM (American Society for Reproductive Medicine) also stated the following: "A study of women with recurrent miscarriages found no evidence of benefit of preimplantation genetic screening in women of any age." It is important to note that PGS (preimplantation genetic screening)/PGT preimplantation genetic testing) may lead to damage to the embryo and may have long-lasting health issues for the newborn. 

Note that neither the sensitivity nor the specificity of the test is 100%. Note that many embryos considered abnormal were transferred resulting in healthy live births.

This patient does not have any genetic anomaly and is not a carrier of a genetic condition or chromosomal anomaly known to cause the birth of a child with a genetic condition. 

In summary, there was no medical indication for PGT-A and PGT-A was not medically necessary.

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

The insurer's denial of coverage for the infertility service, PGT-A, is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain - ACS (Acute coronary syndrome)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This patient is a female; she was hospitalized for chest pain and hypertensive
urgency. The patient had presented to the hospital emergency department for
evaluation of new onset, severe chest pressure, elevated blood pressures in the
180s and headache. Her past medical history was remarkable for migraine
disorder.
The patient's vital signs revealed the blood pressure was initially 181-188/89-106
followed by systolic readings in the 140s-160s range. The plan was to treat her
hypertension with amlodipine five milligrams (MG) daily. There were no arrhythmias
or elevated troponins documented. The patient's electrocardiogram (EKG),
transthoracic echocardiography (TTE), chest computed tomography angiogram
(CTA) and chest x-ray were negative for anything acute and the patient was
discharged to home.

This is an appeal of the denied claim the requested acute inpatient hospital stay was medically necessary for this patient who was approved at the observation level of care.

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

Based on the peer reviewed medical literature, there was not a medical need for the
acute inpatient hospital stay, because the severity of this patient's illness did not
meet the intensity of service for inpatient hospital stay. Per the Milliman Care
Guidelines (MCG) for Chest Pain, #M-89, criteria for inpatient admission are not
met, including hemodynamic instability, respiratory distress, pulmonary edema,
angina with acute coronary syndrome, chest pain that is indicative of a serious
cardiac condition like pulmonary embolism (PE) or aortic dissection, acute
myocardial infarction (AMI), hypertension requiring inpatient hospitalization or any
other medical condition, symptom or finding for which emergency and observation
care have failed or are not considered appropriate. The care this patient received,
including treating new, uncomplicated hypertension like in this case, is routinely
provided safely and effectively at a lower level of care. There was no clinical decline
or inadequate response to treatment which required continuation of the hospital
stay past the observation period. Therefore, based on the submitted information
and the current published medical literature, the proposed treatment, inpatient
hospital admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best
interest of the patient.
The care the patient received, including treating new, uncomplicated hypertension
like in this case, is routinely provided safely and effectively at a lower level of care.
There was no clinical decline or inadequate response to treatment which required
continuation of the hospital stay past the observation period.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ACS (Acute coronary syndrome)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This patient is a female; she was hospitalized for chest pain and hypertensive urgency.  The patient had presented to the hospital emergency department for evaluation of new onset, severe chest pressure, elevated blood pressures in the 180s and headache. Her past medical history was remarkable for migraine disorder. 

The patient's vital signs revealed the blood pressure was initially 181-188/89-106 followed by systolic readings in the 140s-160s range. The plan was to treat her hypertension with amlodipine five milligrams (MG) daily. There were no arrhythmias or elevated troponins documented. The patient's electrocardiogram (EKG), transthoracic echocardiography (TTE), chest computed tomography angiogram (CTA) and chest x-ray were negative for anything acute and the patient was discharged to home. 

This is an appeal of the denied claim the requested acute inpatient hospital stay was medically necessary for this patient approved at the observation level of care.

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

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines (MCG) for Chest Pain, #M-89, criteria for inpatient hospital admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism (PE) or aortic dissection, acute myocardial infarction (AMI), hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care this patient received, including treating new, uncomplicated hypertension like in this case, is routinely provided safely and effectively at a lower level of care. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. Therefore, based on the submitted information and the current published medical literature, the proposed treatment, inpatient hospital admission was not medically necessary.

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

The care the patient received, including treating new, uncomplicated hypertension like in this case, is routinely provided safely and effectively at a lower level of care. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay
Treatment: D2751 white glass with metal crown, Tooth 9
The insurer denied D2751 white glass with metal crown, Tooth 9.
The denial is overturned.

The patient is a male who presented to the office of his dental provider for evaluation and treatment of tooth number (#) 9. Included for review are letters of appeal and denial, a letter from the office of the treatment provider, a narrative from the patient, and a periapical radiographic image of tooth #9.

In question is the medical necessity of the treatment of white glass with metal crown for tooth #9.

The health plan's determination is overturned.

The requested white glass with metal crown for tooth 9 is medically necessary for this patient. Based on the radiographic image, 2/3 of the tooth structure has been previously restored with direct restorations and there is recurrent decay at the distal. This makes the amount of missing/affected tooth structure the majority of the tooth composition, making a direct restoration contraindicated and the indirect, white glass metal crown for tooth #9 medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melena

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission

The denial is upheld

The patient presented after having dark tarry stool. He had a history of having a gastric ulcer and diverticulosis. He was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 12.7. He was treated with Protonix. The patient was placed on a clear liquid diet. There was a plan to do an endoscopy, but he was discharged for outpatient follow up. The hemoglobin remained stable. 

Milliman Care Guidelines (MCG) clinical indications for admission for Upper Gastrointestinal (GI) Bleeding (MCG M-180) include hemodynamic instability, ongoing active bleeding, having a peptic ulcer with high-risk endoscopic features, variceal bleeding, bowel obstruction, peritoneal signs, and the inability to maintain oral hydration. The patient did not have these conditions.

This patient had melena and there was a concern that he could have recurrence of his ulcer disease. He was placed on proton pump inhibitor (PPI) therapy and responded. The hemoglobin remained stable. He decided to have the endoscopy as an outpatient. He did not meet MCG criteria for admission for Upper GI Bleeding. He could have been managed with observation status. 

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: Medical necessity
Decision: Overturned

Diagnosis: Lower Back Pain
Treatment: Outpatient procedure (64484 x 1 and 64484 x 1)
The insurer denied coverage for outpatient procedure (64484 x 1 and 64484 x 1).
The denial is overturned.

According to the documentation provided, this is an adult female with body mass index (BMI) of 27 and intractable lower back pain that she has had for many years. The pain is described as left sided, radiating to the left lower extremity. She has been treated in the past with physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs) without relief. Previous lumbar transforaminal epidural steroid injection (ESI) resulted in almost 100% (percent) pain relief and was reported as lasting months. The same pain has returned at the same location and is rated as 8/10 in severity. There are positive physical exam findings as well as significant degree of functional disability evidenced by inability to walk more than 1 block without pain or limp and inability to perform simple household tasks or regular job duties.

According to Centers for Medicare & Medicaid Services (CMS) guidelines (Epidural Steroid Injections for Pain Management), it is generally not considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months. However, use beyond 12 months may be medically reasonable and necessary if the following criteria are met: pain is severe enough to cause a significant degree of functional disability or vocational disability; the ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline); rationale for the continuation of ESIs including, but not limited to, patient is high-risk surgical candidate, the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three months; the primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use.

Based on the documentation provided, this patient meets the CMS recommended criteria for additional ESI beyond 12 months. She has documented severe disabling pain. She has documented almost 100% pain relief from prior ESI in the same location that lasted almost 18 months (well beyond the recommended three months). 

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

The insurer's denial of coverage for the outpatient procedure (64483 x 1 and 64484 x 1) is overturned. Medical necessity is substantiated.