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

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adult with a past medical history which includes coronary artery disease with a history of myocardial infarction (MI) and two stents, depression, heart failure, cancer, hypertension, hyperlipidemia, obesity, remote tobacco abuse, and diabetes. He presented to the emergency department (ED) with chest pain and dyspnea. Acute coronary syndrome was suspected, and he was admitted to the hospitalist service. Some hours later, prior to his workup being completed, he left the hospital against medical advice (AMA).

His Chest pain was noted to have improved after morphine was given. Uncontrolled hypertension was diagnosed and treated with a change in his antihypertensive medications. Serial troponins and electrocardiograms (EKGs) were planned, along with cardiology consultation, aspirin, and Brilinta.

Two troponins were adequate to exclude myocardial infarction and to confirm his low risk of adverse events in the setting of atypical chest pain.

His subsequent decision to leave AMA is not a relevant factor in assessing the appropriate level of hospital admission. 

In this case, the likelihood that his chest pain was due to coronary ischemia was effectively excluded by the brief observation workup that was completed prior to the patient's discharge; this was the symptom or condition that led to his admission from the ED. For these reasons, inpatient admission was not necessary for the patient.

Based on the above, the insurer's denial must be 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: opioid use.
Treatment: suboxone 8-2mg SL (sublingual) FILM .
The insurer denied suboxone 8-2mg SL (sublingual) FILM. 
The health plan's determination is upheld. 

The patient is a male with a history of opioid use disorder, anemia, and alcohol abuse. According to a visit note, the patient has been taking Suboxone 8-2mg (milligrams) sublingual film four times a day. There was no problem with cravings and no evidence of illicit drug use. The patient is requesting continued coverage of the Suboxone 8-2 four times a day, which is the dose prescribed for about a year due to breakthrough cravings on a lower dose. This is under review.

Suboxone 8-2mg SL (sublingual) FILM was not medically necessary for this patient.
There are no credible controlled trials demonstrating the safety and efficacy of buprenorphine doses greater than 24mg per day, while there is an increased risk of diversion. The fact that the patient has been on a higher dose than 24 mg per day does not in and of itself substantiate the medical necessity of continuing this higher dose. As there are many factors that go into causing opioid withdrawal symptoms, many experts recommend periodic efforts at tapering buprenorphine to see if the patient can now do well on lower doses. There is nothing in this patient's medical records to support the concept that he in particular would not benefit from such an attempt to lower his present dose. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the Suboxone SL 8-2MG film is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 24 hours/day, 7 days/week (split shift)
The insurer denied CDPAS: 24 hours/day, 7 days/week (split shift).
The health plan's determination is overturned. 

The patient is a female with past medical history of congestive heart failure, atrial fibrillation, chronic anticoagulation, osteoarthritis, permanent pacemaker, coronary artery disease, pancreatic cancer, leukemia, and urinary incontinence who had been provided Consumer Directed Personal Assistance Services (CDPAS).

CDPAS: 24 hours/day, 7 days/week (split shift) are medically necessary for this patient.

The patient's medical provider documented medical necessity of increased CDPAS. The plan's own assessment noted an increase in assistance needs with multiple activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient requires at least maximum assistance with walking, locomotion, transfer toilet, bed mobility, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these needs. Overnight care logs documented for 1 month demonstrated the patient has overnight assistance needs at least every 3 hours, which would not allow an aide 5 hours of uninterrupted sleep. The requested increase in CDPAS is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS: 24 hours/day, 7 days/week (split shift) 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: psoriasis vulgaris
Treatment is Skyrizi Pen 150 mg (milligrams)/ml (milliliters) SC (subcutaneous) SOAJ (solution auto-injector)
The insurer denied coverage for Skyrizi Pen 150 mg/ml SC SOAJ.
The denial is overturned.

The patient is an adult with a diagnosis of psoriasis vulgaris. The patient has severe psoriasis affecting 40% (percent) total body surface area (TBSA) and has failed therapy with multiple topical agents, including calcipotriene, clobetasol, fluocinolone, Vtama, and mometasone. The patient has also failed a trial of oral Methotrexate due to nausea and vomiting. The requested medication is Skyrizi.  

Based on the submitted documentation, Skyrizi is medically necessary. The patient has failed topical therapy and requires systemic therapy for control and management of her psoriasis diagnosis. The patient has tried and failed topical agents as well as Methotrexate. Skyrizi is FDA (Food and Drug Administration) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this treatment option.  

The joint AAD (American Academy of Dermatology)-NPF (National Psoriasis Foundation) guidelines for psoriasis treatment with biologics states, "A RCT (randomized control trial) assigned 166 patients to receive risankizumab subcutaneously (a single 18-mg dose at week 0 or 90-mg or 180-mg doses at weeks 0, 4, and 16) or ustekinumab (45 or 90 mg [depending on body weight] at weeks 0, 4, and 16). At week 12, 77% of patients receiving risankizumab (the 90-mg and 180- mg groups pooled), as compared with 40% in the ustekinumab-treated group, achieved PASI (Psoriasis Area and Severity Index) 90 (P (probability)\ .001); in contrast, 45% in the pooled groups treated with 90 mg and 180 mg of risankizumab, as compared with 18% in the ustekinumab-treated group, achieved PASI 100.

In this case, Skyrizi is a reasonable next therapy for the treatment of the patient's disease and is medically necessary having failed therapy with Methotrexate and numerous topical agents.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Skyrizi Pen 150 mg/ml SC SOAJ is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis.
Treatment: Personal Care Services: 70 Hours per Week.
The insurer denied Personal Care Services: 70 Hours per Week.
The determination is overturned.

This is a female patient with a medical history notable for multiple sclerosis. The patient is currently residing in a skilled nursing facility and working toward a safe discharge plan home. Prior to being admitted to the facility, she was receiving 58 personal care service hours per week. The patient and her care team requested an increase to 70 hours per week, and this request was denied by the health plan.
Physical therapy and case management notes were provided and reviewed in detail. The patient's discharge from the skilled nursing facility was denied due to the lack of additional hours being approved; without the additional hours, they felt it would not be a safe discharge plan. She has some informal assistance, but it cannot be reliably available. She requires a Hoyer lift to transfer to a motorized wheelchair.
A neurology office visit note was provided for review. It details concern for progression of her multiple sclerosis.
A Uniform Assessment System (UAS) was completed. The assessment was conducted in person at the skilled nursing facility with the goal of discharge home for the patient. The patient was alert and oriented with a Montreal Cognitive Assessment (MOCA) score of 29/30 which is consistent with normal cognition. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, stairs, and transportation. She requires maximal assistance for finances, medication, and shopping. She is independent for phone use. For her activities of daily living (ADLs), she requires total dependence for dressing lower body and toilet use. She requires maximal assistance for bathing and bed mobility. She requires extensive assistance for dressing upper body. She is independent for hygiene. She is frequently incontinent of urine (daily) and occasionally incontinent of stool. She wears pullups for incontinence care. A task tool associated with the assessment recommended 48.48 hours per week to address her personal care needs. At issue is the medical necessity of Personal Care Services: 70 Hours per Week.

The requested health service of Personal Care Services: 70 Hours per Week is medically necessary for this patient.
The patient requires assistance for multiple ADLs and IADLs due to the chronic and progressive nature of her multiple sclerosis. She is cognitively intact and able to direct her own care. She is currently residing in a skilled nursing facility and is a good candidate to return to the community with assistance in the home. Given her lack of informal support, the increase in personal care services to 70 hours per week is medically necessary and reasonable. She is not able to transfer or toilet without assistance, and thus it would not be reasonable to expect her to schedule all of her personal care within a shorter shift each day. Her needs may be continuous and unscheduled in nature and the task tool may underrepresent her true needs.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure. 

The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a female patient with diagnoses that include Back Pain; Spondylosis without Myelopathy or Radiculopathy, Lumbar Region; Vertebrogenic Low Back Pain, Low Back Pain, Vertebral Endplate Pain; Other Intervertebral Disc Degeneration, Lumbar; Lumbar Herniated Disc, Lumbar Degenerative Disc Disease, Lumbar Radiculopathy. Records provided note that the patient was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance carrier. 

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The patient is noted to have a history of low back pain with radiculopathy and has undergone multiple lumbar epidural injections with benefit. The provider states that the patient had a lumbar spine magnetic resonance imaging (MRI) showing Modic changes at disc spaces L5 and S1. However, the MRI report submitted for review showed a disc bulge at L5 - S1 with encroachment of the left transiting S-1 nerve root and facet joint arthrosis. There was no mention of Modic changes or degenerative endplate changes. There is no documentation showing the patient had attempted any procedures to address the facet joint arthrosis which could be a pain generator as well. 

This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure. 

The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is overturned. 

This patient is a female who has chronic lower back pain with radiating pain to the left leg. 90% of the pain is in the lower back with 10% of pain in the leg. Her pain is dull and achy, increased by lifting and prolonged sitting standing. She had tried physical therapy, lumbar spinal injections and pain medications without adequate pain relief. Her pain level is 7/10. She was recommended to have L5-S1 intercept procedure. Physical exam was unremarkable except painful lumbar spine range of motion with flexion more than extension. Lumbar spine magnetic resonance imaging (MRI) reviewed a mild disc bulge at L5-S1 level with Modic changes. 

The Intraosseous Basivertebral Nerve Ablation Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The Intraosseous nerve ablation procedure was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent low back pain is consistent with vertebrogenic pain. She had tried physical therapy, lumbar spinal injections and pain medications without adequate pain relief. Her pain level is 7/10. Further interventions are indicated to improve her pain and function. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intraosseous Basivertebral Nerve Ablation Procedure is likely to be more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure. 

The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

The patient is a female with a history of low back pain. She was treated with epidural injections, physical therapy, CBD (cannabidiol) products, and gabapentin. On exam, there was tenderness in the spine with normal sensation, reflexes and strength. A magnetic resonance imaging (MRI) of the lumbar spine, revealed disc bulging. 

The proposed Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The Intracept procedure is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. While a recent study has shown promising results, the limitation of most of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up. 

In this case, the Intracept procedure is not supported by the literature to offer long term relief and the treating provider does not offer any specific rationale on how this intervention would offer any long-term relief for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Gastroesophageal Reflux Disease/GERD.
Treatment:  Surgical Services (All)- LINX Procedure.

The insurer denied Surgical Services (All)- LINX Procedure.  The determination is overturned.

This patient is diagnosed with refractory gastroesophageal reflux disease (GERD). The patient has a Demeester score is 37. Manometry was normal. An esophagogastroduodenoscopy (EGD) showed small hiatal hernia and esophagitis. At issue is the proposed service/treatment, LINX procedure.

This patient has severe gastroesophageal reflux disease (GERD) and is refractory to medications. As per Society of American Gastrointestinal and Endoscopic Surgeons, longer-term (3-5 years) experience with the LINX Reflux Management System confirms the initial safety profile that led to Food and Drug Administration (FDA) approval of the device. The LINX device has been demonstrated to result in long-term gastroesophageal reflux disease (GERD) control based on symptomatic outcomes, proton pump inhibitor (PPI) utilization, and potential hydrogen (pH) studies. The LINX is a reasonable treatment option for appropriately selected patients with gastroesophageal reflux disease (GERD) who meet indications for anti-reflux surgery. The LINX procedure is part of the armamentarium in the treatment of gastroesophageal reflux disease (GERD). As such, it should be performed by surgeons familiar with the workup and different management alternatives of gastroesophageal reflux disease (GERD) and not offered in isolation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Gastroesophageal Reflux Disease/GERD.
Treatment:  Surgical Services (All)- LINX Procedure.

The insurer denied Surgical Services (All)- LINX Procedure.  The determination is overturned.

This patient has a body mass index (BMI) of 30 kilograms per square meter (kg/m2) and complaints of long-standing gastroesophageal reflux disease (GERD) despite medication use. The patient had a 24-hour potential hydrogen (pH) study that reported a DeMeester score of 37 consistent with (c/w) severe gastroesophageal reflux disease (GERD). Upper gastrointestinal (UGI) exam showed a small hiatal hernia with severe gastroesophageal reflux disease (GERD). Endoscopy revealed esophagitis without evidence of Barrett's esophagus. At issue is the proposed health service/treatment of LINX Procedure.

This patient has gastroesophageal reflux disease (GERD) refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both treatments have been shown in published studies to be more effective than medical management. The LINX procedure is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on published literature to be a standard surgical treatment for gastroesophageal reflux disease (GERD) in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to the LINX and Nissen fundoplication procedures include body mass index (BMI) greater than 35 kilograms per square meter (kg/m2) in which case treatment of obesity is thought to be important for treatment of gastroesophageal reflux disease (GERD). Other exclusions for LINX include Barrett's esophagus with dysplasia, age less than 18, large hiatal hernia greater than 3 centimeters (cm), and prior gastric or bariatric surgery. This patient has no contraindication to treatment and meets standard surgical treatment for gastroesophageal reflux disease (GERD).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 
 
Patient is an adult female with a history of chronic obstructive pulmonary disease (COPD), asthma and hypertension. She presented to the emergency department (ED) with complaints of shortness of breath (SOB), chest tightness and abdominal pain. The patient had been non compliant with her asthma and COPD medications. She had run out of them and was not following up with her doctor. 

At presentation to the ED her Temperature was 98 degrees F, Heart Rate 98, Respirations 20, Blood Pressure 110/75 and oxygen saturation on room air was 95%. The patient was noted to have bilateral wheezing. She was treated with intravenous (IV) steroids, bronchodilators and magnesium. The patient was admitted with a diagnosis of COPD / asthma exacerbation. 

As per the history and physical; the patient was afebrile, hemodynamically stable and in no acute distress. She was speaking full sentences. Lung exam revealed bilateral wheezes. Abdomen revealed an incisional hernia which was reducible. The patient was fully alert and oriented to person, place and time. 

White blood cells were 4,400, Hemoglobin 11.9, electrolytes were within normal limits except for a mildly decreased potassium (K+). Chest x-ray showed no acute infiltrates. Electrocardiogram (EKG) had no acute ischemic changes. Venous blood gas was potential of hydrogen (pH) 7.39 and CO2 46. Computed tomography of the abdomen demonstrated an Abdominal Ventral hernia unchanged from prior studies. 

Patient was continued on intravenous (IV) steroids and bronchodilators. Electrolytes were replaced as needed. The patient was given some Morphine for abdominal pain. She was evaluated by surgery for her ventral hernia. No signs of obstruction noted. It was reducible. Outpatient follow-up was recommended. She was switched to oral steroids and discharged with outpatient follow-up. 

This patient did not need acute inpatient hospitalization. Her COPD was mild. It was precipitated by non compliance with her medications. She was afebrile, hemodynamically stable, not hypoxic, no pneumonia, white blood count (WBC) normal and pH was normal. This patient could have been placed in observation status while diagnostic testing and treatment were continued. The observation could be for up to 48 hours. This patient remained stable after admission, and she could have been discharged home on oral steroids and her bronchodilators (which she had run out of triggering this admission). She was tolerating food and fluids. She could have been followed up closely as an outpatient after discharge.

Based on the above, the insurer's denial must be 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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 Braces, D8670 Monthly Visits.

The insurer denied D8080 Braces, D8670 Monthly Visits.  The denial is overturned.

The patient is an adolescent male. The request is for orthodontic benefits and monthly visits. He has a Class II malocclusion, deep, impinging overbite and an impacted upper right canine. The health plan's prior denial of coverage was due to a handicapping index score of 13. The denial is being appealed.

The requested braces and monthly visits are medically necessary.

The patient has an impacted upper right permanent canine where extraction is not indicated. He also has an overjet of more than 9mm (millimeters) with incompetent lips and speech problems. Both of these issues are automatic qualifiers according to the handicapping index scale. Orthodontic treatment is needed to correct these issues. The case has medical necessity.