Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: End-Stage Non-Ischemic Cardiomyopathy

Treatment: LifeVest device (procedure code K0606)

The insurer denied coverage for LifeVest device (procedure code K0606)

The denial is overturned.

The patient has a history of breast cancer status post bilateral mastectomy, prophylactic hysterectomy and congestive heart failure (CHF). Echocardiography performed demonstrated severe left ventricular systolic dysfunction with ejection fraction less than (<) 20% (percent), moderate to severe mitral regurgitation, moderate tricuspid regurgitation, and pulmonary hypertension. She was admitted for cardiogenic shock and started on intravenous milrinone. She received an Impella circulatory support pump. She also was started on guideline-directed medical therapy for cardiomyopathy. Coronary angiography showed angiographically normal coronary Subsequently she underwent magnetic resonance imaging, which revealed severely reduced left ventricular systolic function with an ejection fraction of 26%, with severe right ventricular systolic function of 20%.  Findings were consistent with non-ischemic cardiomyopathy. The patient was prescribed a wearable cardioverter defibrillation (WCD) for the treatment of dilated cardiomyopathy. She presented to the Cardiologist's office for management of end stage nonischemic cardiomyopathy. The patient continued to have New York Heart Association (NYHA) class IIIa symptoms. She appeared to be euvolemic on her loop diuretic regimen. The physician stated that the patient would be an excellent candidate for heart transplantation, pending repeat computed tomography (CT) scan to follow-up on previously seen ground glass opacifications. 

The Life Vest is Federal food and drug administration (FDA) approved for prevention of sudden cardiac death. This technology does not have evidence-based proven efficacy for prevention of sudden cardiac death; however, it may be used in certain clinical circumstances when an implantable cardioverter-defibrillator is inappropriate. Examples of this include infection requiring explanation of a prior indwelling defibrillator or if the patient is a candidate for a heart transplant, whereby the risk of infection for implantable defibrillator should be avoided. While the patient was not on a transplant waiting list, her candidacy for transplant is evident, and therefore she is an appropriate and suitable candidate for a wearable cardioverter-defibrillator. In addition to supportive care and guideline-directed medical therapy, the Life Vest is the next best available treatment for this patient while awaiting heart transplantation consideration. The use of Life Vest. The life vest is likely to be more beneficial in the treatment of this patient and the adverse risk are not increased over other standard therapy.

The carrier's denial of the LifeVest device (procedure code K0606) provided should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Erectile Dysfunction

Treatment: procedure to straighten the penis (procedure code 54360)

The insurer denied coverage for procedure to straighten the penis (procedure code 54360)

The denial is upheld.

This is an adult male with history of status post penile implant placed several years ago, status post urolift, diabetes, hypertension, status post right hemicolectomy, history of increase prostate specific antigen (PSA), hematuria. While passing a left ureteral stone the patient mentioned that his penile implant (inflatable) was not functioning properly. The patient discussed possible revision surgery. The patient was then taken to operating room for revision/replacement of a malfunctioning penile prosthesis. Testing revealed a non-functional 3-piece penile prosthesis. The operation was then carried out to replace the penile prosthesis but billed out as a procedure to fix penile curvature. 

The insurer has denied coverage for procedure code 54360 which involves penile straightening as not medically necessary. They stated the records do not support a penile plication procedure, which is usually performed for treatment of peyronie's disease. 

The patient is appealing. 

Review of the Operative note indicates preoperative/postoperative diagnosis of erectile dysfunction, malfunctioning of penile prosthesis, and the procedure was implant of coloplast titan penile prosthesis. There is no mention of peyronie's disease, penile curvature, or penile placation - penile straightening procedure. The operative note does indicate increased difficulty of this procedure due to scar tissue from prior operation but does not mention need for penile plication procedure to straighten out the penis.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. For the procedure code 54360, noted as performed, the submitted records do not support the procedure was done or that there was medical necessity for procedure for this patient.

The insurer's denial of coverage for procedure code 54360, provided is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This is the case of a female patient with past medical history of gastric bypass, abdominoplasty, and obesity who presented to the hospital for fevers and associated right flank pain. Computed tomography (CT) scan of abdomen and pelvis revealed multiple hypoattenuating areas in right kidney along with 2.5 centimeters (cm) area in interpolar region of right kidney, concerning for phlegmon or abscess. The patient was admitted, urology consulted, the patient was given ceftriaxone, urine culture returned no growth. The patient's white blood cell (WBC) count was low, she signed out against medical advice (AMA). 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. They noted the presentation and admission, and the services rendered did not require an inpatient hospital admission. 

The appeal on behalf of the patient is noted and read in detail. Per Milliman Care Guideline (MCG) Health (24th): 
- Urinary tract infection (UTI) 
- Sepsis + Other Febrile Illness without Focal Infection. 

The patient fails to meet clinical indications for admission to inpatient care. There is no evidence of hemodynamic instability, altered mental status, persistence or worsening of clinical findings despite observation care treatment, parenteral antibiotics needed beyond observation period, pregnancy of 24 weeks gestation or beyond, etc. No urinary system findings requiring invasive procedure, no acute renal failure, no immunocompromised state. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

The inpatient hospital admission was not considered medical necessary for this patient. 

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

Diagnosis: PCOS; anovulation
Treatment: Artificial Insemination; Intra Uterine (IUI) (58322)
The insurer denied the Artificial Insemination; Intra Uterine (IUI) (58322)
The denial is upheld. 

The patient is a female with a diagnosis of PCOS (polycystic ovarian syndrome) and anovulation. She has been trying to get pregnant for a year.  Her hysterosalpingogram was normal. The semen analysis was normal.  The provider decided to proceed with induction of ovulation with letrozole, hCG (Human Chorionic Gonadotropin) trigger and intrauterine insemination.

No, the Artificial Insemination; Intra Uterine (IUI) (58322) is not medically necessary.
This patient has anovulatory cycles.  In order for her to conceive, she needs to ovulate. Standard of care for patients such as this would include treatment for anovulation.  However, this patient does not have infertility due to a male factor.

So at this time, intrauterine insemination is not needed.  Only if the patient fails to conceive after one year of ovulatory cycles will she be labeled as having a diagnosis of infertility, and thus appropriate for infertility services, including intrauterine insemination.

Note that according to the scientific literature, compared to timed intercourse, IUI (intrauterine insemination) does not increase the pregnancy rate in couples with PCOS (polycystic ovarian syndrome) and normal semen analysis treated with controlled ovarian stimulation.

The health plan decision is in agreement with the scientific data that showed that intrauterine insemination for this patient is not indicated since the patient does not have a diagnosis of infertility.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess Skin of Eyelid

Treatment eyelid and brow surgery

The insurer denied coverage for eyelid and brow surgery.

The denial is upheld.

This is an adult female with a history of asthma, gastroesophageal reflux disease (GERD), asthma and weight loss after a sleeve gastrectomy. She presented to the Plastic Surgeon's office for a preoperative evaluation for eyelid and brow surgery.

The insurer has denied the request for surgery.

According to the American Academy of Ophthalmology (AAO), blepharoplasty procedures and repair of blepharoptosis are considered as functional/reconstructive surgery to correct: 

-	Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis
-	Symptomatic redundant skin weighing down upper lashes
-	Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin
-	Prosthesis difficulties in an anophthalmic socket

Documented patient complaints which justify functional surgery and are commonly found in patients with ptosis, pseudoptosis, or dermatochalasis include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis. Photographs should demonstrate one or more of the following: 

-	The upper eyelid margin approaches to within 2.5 millimeter (mm) (1/4 of the diameter of the visible iris) of the corneal light reflex
-	The upper eyelid skin rests on the eyelashes
-	The upper eyelid indicates the presence of dermatitis
-	The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket
-	Visual fields recorded to demonstrate a minimum of 12 degree or 30 percent loss of upper field of vision with upper lid skin and/or upper margin in repose and elevated (by taping of the lid) to demonstrate potential correction by proposed procedure or procedures.

This patient's margin to reflex distance (MRD) measurements are > 2.5 mm based on the photos. She does have upper eyelid skin that rests on the lashes, but visual field studies are not provided for review to confirm at least 12-degrees of field loss. The AAO guidelines require visual field tests to confirm the presence of visually significant field cuts, but automated perimetry testing results are not provided. The AAO guidelines are not met, and the request is therefore not medically necessary.

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

The insurer's denial of coverage for eyelid and brow surgery is upheld. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ST elevation myocardial infarction.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with a past medical history significant for CHF (congestive heart failure), cardiomyopathy, obesity, COPD (chronic obstructive pulmonary disease), sleep apnea, diabetes mellitus type 2, and tobacco abuse. He presented to an outside hospital with dyspnea and was found to have a mediastinal mass. The patient was being worked up for biopsy by IR (interventional radiology), when his course was complicated by an acute myocardial infarction with ST elevation (STEMI). The patient was loaded with anti-platelets and started on Heparin. He was transferred for primary PCI (percutaneous coronary intervention).

Cardiac catheterization was done emergently for STEMI (ST elevation myocardial infarction), and a primary PCI (percutaneous coronary intervention) of a first diagonal branch of the LAD (left anterior descending artery) was performed with POBA (plain old balloon angioplasty). No stent was placed, given the need for mediastinal mass biopsy in the near future.

Post procedure, the patient's course was complicated by significant nasopharyngeal bleeding, requiring ENT (otolaryngology) intervention. The patient was monitored and stabilized in CCU (coronary care unit). His bleeding stopped and he was discharged with a plan for outpatient follow-up and work-up of his tumor.

Yes, the Inpatient admission was medically necessary.

The patient presented with an acute ST elevation myocardial infarction (STEMI) and underwent cardiac catheterization with a primary PTCA (Percutaneous Transluminal Coronary Angioplasty) of the culprit vessel. His course was further complicated by nasopharyngeal bleeding. Given the presentation, bleeding complications, as well as diagnosis of acute coronary syndrome/STEMI (ST elevation myocardial infarction), he would not be an appropriate candidate for an ambulatory procedure. It would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stable left knee status post anterior cruciate ligament (ACL) reconstruction

Treatment: Ongoing Physical Therapy - 18 physical therapy visits

The insurer denied coverage for ongoing physical therapy - 18 physical therapy visits.

The denial is upheld.

The patient is a female diagnosed with stable left knee status post anterior cruciate ligament (ACL) reconstruction. The physical examination revealed the patient had healed incisions on the left knee. The patient had no effusion in the left knee. She had good extension, but lacked approximately 1-2 degrees of hyperextension of the left knee compared to the right knee. She had flexion of her right knee of approximately 148 degrees. There was no tenderness of the patellar tendon and motor, and sensation was intact. The treatment plan included continuing to attend physical therapy (PT) to work on body weight strengthening exercises. The patient was not approved to work on any sort of increased strengthening exercises, run, jump, or participate in sports. The patient was given a prescription to return to the jogging program with no agility drills. The patient was almost 5 months out from the left knee ACL reconstruction with patellar tendon autograft. She was doing well with no complaints. She had been going to PT and was running 2-3 miles at a time, continuously, multiple days per week. 

The patient had left ACL surgery and had her initial evaluation and treatment visit with PT. She was approved for an additional 6 therapy visits. It was noted that the patient was doing well and had made good progress and returned to a jogging program. She was doing well with no complaints and was running 2-3 miles at a time multiple days per week. Given the patient's amount of recovery and functional improvement and independence with activities and home exercise program there is a lack of documented medical necessity for continued supervised one on one skilled therapy. There is a lack of documented inability to continue making progress with a home exercise and training program and the request for additional supervised PT is not medically necessary at this time.

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

Coverage for ongoing physical therapy - 18 physical therapy visits is not considered medically necessary for this patient

The insurer's denial of coverage for ongoing physical therapy - 18 physical therapy visits is upheld. Medical necessity not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Foot Cellulitis

Treatment: Inpatient emergency admission

The insurer denied coverage for inpatient emergency admission.	

The denial is upheld.

This patient is a female with past medical history significant for morbid obesity, hypertension, congestive heart failure, and lymphedema who presented to the emergency department with complaints of shortness of breath, and left foot swelling and pain. Vitals on presentation included: Temperature 98.8, Blood Pressure 132/84, Pulse 105, Respiratory Rate 20, oxygen (O2) saturation - 97% (percent) on room air. Laboratory results included the following: white blood count (WBC) - 9.1, hemoglobin (HGB) - 11.5, hematocrit (HCT) - 37.4, creatinine - 0.83, glucose - 103, B-type natriuretic peptide (BNP) <10. 

This patient was admitted to the hospital for a possible left foot cellulitis. She was empirically started on antibiotics (cefazolin and doxycycline). Chest x-ray (CXR) was negative. X-ray of foot showed no dislocation, no fracture. All cultures were negative. The patient had a hypertensive episode that was believed to be secondary to anxiety. The patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management.

According to documentation, the patient presented with left foot swelling. Otherwise, she was afebrile and hemodynamically stable with unremarkable laboratory results including a normal WBC. Imaging studies including CXR and foot x-rays were also negative. Based on above findings, the patient did not meet criteria for acute inpatient care. 

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

Based on the above, the medical necessity for the inpatient emergency admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure postictal state

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient was brought in by ambulance to the emergency department for a seizure.  The blood pressure was 137/69.  The mental status was uncooperative.  Glasgow Coma scale score was 14.  The patient appeared post ictal.  The vital signs were stable.  The patient moved all extremities.  The patient was argumentative and uncooperative.  The patient was hostile.  The patient was refusing a cardiac monitor and only answered some questions.  The patient reported taking his seizure medications.  The patient was actively seizing and was medicated.  The patient was to be admitted. The patient was postictal and was in no acute distress and the patient was admitted to medicine and was awaiting bed placement. The patient became agitated and pulled out the IV (intravenous) lines and signed out against medical advice (AMA).  The patient was following up with his neurologist.  The patient was in no acute distress upon ambulating out of the emergency department.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient presented to the emergency department (ED) in a postictal state. The patient was treated with intravenous (IV) Keppra and IV fluids and his anticonvulsant blood levels were sub-therapeutic. The member left the hospital against medical advice (AMA). Care provided could have been performed in the ED and at an observation level of care.

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

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld.

This is the case of an adult male patient that presented to the hospital with near syncope and a fall. Past medical history was significant for hypertension, diabetes mellitus and hyperlipidemia. The patient reported feeling lightheaded and then he lost his vision prior to falling and hitting his head. On exam, his vital signs were stable with blood pressure (BP) of 127/84 and pulse of 63 beats per minute and no signs of head or face trauma were noted. Head computed tomography (CT) revealed no abnormality. Serum blood testing revealed hypokalemia and acute kidney injury (AKI) with a creatinine of 1.9 milligrams/deciliter (mg/dl) and a blood urea nitrogen (BUN) of 29 mg/dl. The patient was treated with intravenous (IV) fluids and electrolyte repletion and admitted to the hospital. Toxicology screen was positive for cannabis. Electrocardiogram (ECG) revealed normal sinus rhythm with a normal axis and normal intervals.

According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality. (1) In a study of individuals presenting to the Emergency Room, patients that were low-risk or intermediate-risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing. (2)

This patient presented with syncope that occurred with gradual onset preceded by lightheadedness. Evaluation in the Emergency Department (ED) revealed no evidence of intracranial pathology on CT head. Serum blood testing was significant for marijuana use and an elevated BUN/creatinine ratio supporting an etiology of volume depletion. The patient was discharged the following day. In this case, the patient falls into a low-risk category and could be managed at a lower level of care. Acute inpatient admission was not medically necessary. 

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

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

Diagnosis: Lumbar spinal stenosis
Treatment: Percutaneous laminotomy/laminectomy (intralaminar approach)
The insurer denied the percutaneous laminotomy/laminectomy (intralaminar approach).
The denial is overturned.

The patient is an adult male with history of chronic low back pain due to lumbar spinal stenosis and associated with intermittent claudication. He failed all other conservative measures. The alternative is for a major surgical decompression, as compared to the requested procedure, which is minimally invasive percutaneous laminotomy.

Yes, the requested Percutaneous  laminotomy/laminectomy (intralaminar approach) is medically necessary.

The requested percutaneous inter laminar laminotomy/laminectomy is proven and indicated in the treatment of low back pain secondary to lumbar spinal stenosis with intermittent claudication.

According to Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment, there is a Level 1 evidence for percutaneous image-guided Lumbar Decompression as superior to lumbar epidural steroid injections, including five controlled prospective studies and 17 other retrospective studies, case series, meta-analyses, etc published in peer-reviewed journals.

The percutaneous inter laminar laminotomy/laminectomy procedure has been shown to be at least as effective for other pain procedures, less invasive, effective in improving pain, and such is achievable in standard conditions of medical practice as published in multiple peer-reviewed journals, some listed in the references below.

The patient has history of chronic low back pain due to lumbar stenosis with intermittent claudication, therefore, given this and the above, the requested percutaneous laminotomy/laminectomy (intralaminar approach) is medically necessary for this patient.