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

Diagnosis: Left Gluteal Abscess

Treatment: inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is overturned.

This is the case of an immunocompromised female patient with a past medical history significant for diabetes mellitus who presented to the emergency department with complaints of pain and swelling to left gluteal area.  Vitals on presentation included: Temperature 97.7 Fahrenheit, Blood Pressure 123/77, Pulse 92, Respiratory Rate 18, oxygen saturations 100% (percent) on room air. Laboratory values were notable for the following: white blood cell (WBC) 5.5, hemoglobin (Hgb) 12.2, hematocrit (Hct) 37.4, creatinine 0.48, and glucose 106.

The patient was empirically started on broad-spectrum IV (intravenous) antibiotics (vancomycin, cefepime, and metronidazole) for left buttock abscess. Surgery consulted and performed an I&D (Incision and Drainage) of the buttock abscess under anesthesia. Post-operatively, she remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics as an outpatient.  

According to documentation, the patient presented with worsening left buttock abscess despite recent hospital admission and discharge on oral antibiotics. Patient required I&D of left 7 x 8 cm (centimeters) gluteal abscess with extension to the muscle; a left transsphincteric fistula was also noted. Based on above findings, in a high-risk patient with immunocompromised status, diabetes mellitus, and failure of outpatient management, hospital admission was medically necessary for IV antibiotics and surgical intervention.  

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

The insurer's denial of coverage for the inpatient hospital stay is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital hypotonia
Treatment: Private Duty Nursing To 84 Hours Per Week (home health care)
The insurer denied the Private Duty Nursing To 84 Hours Per Week (home healthcare)
The denial is overturned.

This patient has a diagnosis of congenital hypotonia.  This is an appeal of
denial of PDN (private duty nursing) 84 hours per week.  The patient has been approved for PDN 60 hours per week.

A letter from the provider states the patient was recently hospitalized with RSV (respiratory syncytial virus) pneumonia and right collapsed lung.  He was sent home on oxygen and is continuously monitored by pulse oximetry.  He requires nebulizer and suctioning multiple times throughout the day.  He is G-tube (gastrostomy tube) dependent.  He needs assistance with positions for sleep.  The recommendation is for nursing care 12 hours per day, 7 days per week.

Nursing assessment shows oxygen adjusted based on oxygen status. He needs frequent oral/nasal suctioning and requires chest PT (physical therapy) and nebulizer every 2 hours.  He is incontinent when asleep.  The patient is receiving PT (physical therapy) and OT (occupational therapy).  The patient has foot AFOs (ankle foot orthosis).  He is in a stroller when outdoors.  He uses lubricant eye drops every 2 hours.  Enteral feedings are given four times per day.  He is totally dependent with ADLs (activities of daily living), except minimal assistance with ambulation and transferring.

Yes.  The requested health service is medically necessary.  The service is consistent with standard of care.

Private duty nursing is medically necessary for continuous, substantial and complex hourly nursing services provided by a licensed nurse in the patient's home.  Private duty nursing is skilled nursing care provided on a one-to-one basis.  Private duty nursing is not indicated for maintenance care.  This patient has congenital hypotonia and is totally dependent with all ADLs (activities of daily living).  He does have maintenance care needs including feeding via G tube, diaper change and medication administration.  He was also recently hospitalized with pneumonia and pneumothorax.  Since discharge he has been on oxygen with adjustments based on pulse oximetry.  In addition, he requires frequent nebulizer, suctioning and chest PT (physical therapy).  Based on this patient's recent hospitalization and new needs related to frequent management of his respiratory system, hands-on
nursing intervention is medically necessary.  As such, the requested PDN (Private Duty Nursing) 84 hours per week is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Depression.

Treatment: procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour); ketamine intravenous infusion therapy.

The insurer denied coverage for procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour); ketamine intravenous infusion therapy.

The denial is upheld.

This patient has a history of post-traumatic stress disorder, major depression disorder, and generalized anxiety disorder.  The patient has been under the care of the Anesthesiologist received intravenous (IV) ketamine therapy.

Ketamine or Esketamine may be indicated for treatment resistant depression, severe unipolar without psychotic features, if patients have failed other indicated treatments for resistant depression. A patient receiving ketamine or esketamine should be under the care of psychiatrist who can determine whether other treatments have been appropriately administered and can monitor the outcome of the ketamine/esketamine trial.

For patients with unipolar major depression who do not respond to initial treatment with an antidepressant medication, treatment strategies include:

1) Augmentation (adding a treatment)
2) Medication (eg, second-generation antipsychotic, lithium, a second antidepressant, or triiodothyronine)
3) Psychotherapy
4) Electroconvulsive therapy
5) Repetitive transcranial magnetic stimulation
6) Supplementary and supportive interventions such as exercise

7) Switching treatment
8) Different antidepressant
9) Psychotherapy
10) Electroconvulsive therapy
11) Repetitive transcranial magnetic stimulation.

There is information about the patient failing trials or having side effects to Lexapro, Buspirone, Latuda, Lamictal, Wellbutrin and Zoloft. There is no information from treating psychiatrist, psychiatric assessment and information if other recommended pharmacological (augmentation) or non-pharmacological interventions were tried. 

A patient receiving ketamine or esketamine should be under the care of psychiatrist who can determine whether other treatments have been appropriately administered and can monitor the outcome of the ketamine/esketamine trial. There is no initial evaluation showing the baseline symptoms and ongoing assessment (rating scales) monitoring progress/outcome. 

There is no information supporting that requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. The risks are not increase over other standard treatments.

The carrier's denial of procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour (ketamine intravenous infusion therapy) should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Depression.

Treatment: procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour); ketamine intravenous infusion therapy.

The insurer denied coverage for procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour); ketamine intravenous infusion therapy.

The denial is overturned.

According to the documentation submitted, this is the case of a patient with a history of post-traumatic stress disorder, major depressive disorder and generalized anxiety disorder.  The patient has been under the care of Anesthesiologist and received intravenous (IV) ketamine therapy. The insurer has denied ketamine.

Philips et al. (1) found that compared with midazolam, a single ketamine infusion elicited a significantly greater reduction in depressive symptoms at the primary efficacy endpoint (24 hours post infusion). Linear mixed models revealed cumulative antidepressant effects with repeated infusions and doubling of the antidepressant response rate. Fifty-nine percent of participants met response criteria after repeated infusions, with a median of three infusions required before achieving a response.

They concluded that: "Repeated ketamine infusions have cumulative and sustained antidepressant effects. Reductions in depressive symptoms were maintained among responders through once-weekly infusions. These findings provide novel data on efficacious administration strategies for ketamine in patients with treatment-resistant depression."

Marcantoni et al. (3) conducted a meta-analysis of Twenty-eight studies in 35 publications. "A strong ketamine effect was observed within 4 hours following a single infusion and peaked at 24 hours. Ketamine's effectiveness was still present, yet somewhat diminished, 7 days post-infusion. Multiple infusions resulted in an enhanced and prolonged ketamine effect."

Correia-Melo et al. (4) conducted a head-to-head comparison between Esketamine, (which this patient has previously taken successfully) and racemic Ketamine and found: "Esketamine was non-inferior to ketamine for TRD [treatment resistant depression] 24 hour following infusion. Both treatments were effective, safe, and well tolerated."

The patient has had prior good results with Esketamine. IV infusions of racemic Ketamine are medically equivalent. The patient is a good candidate for this treatment, the literature has proven efficacy. This treatment is likely to be more beneficial than any standard services without increased risk.

The carrier's denial of procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour) (ketamine intravenous infusion therapy) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease) 
Treatment: Linx Reflux Management System
The insurer denied the Linx Reflux Management System
The denial is overturned. 

The patient is a male. His BMI (body mass index) is 28. The request is for 43284 magnetic sphincter augmentation for GERD (gastroesophageal reflux disease).  The patient's pertinent past medical history includes GERD (gastroesophageal reflux disease) on PPI (proton pump inhibitor) - omeprazole 40mg (milligrams) BID (twice daily) and famotidine 40mg (milligrams) qhs (nightly).

Despite maximal medical management, the patient's symptoms are uncontrolled.  His workup has included EGD (esophagogastroduodenoscopy) that was normal, pH (potential of hydrogen) testing on antacids that was normal, but pH (potential of hydrogen) testing off antacids showed a demeester score of 40 and % time of 12% consistent with GERD (gastroesophageal reflux disease), and an UGI (upper gastrointestinal series) that showed reflux to the clavicles.  The patient's procedure was previously denied with the rationale that magnetic sphincter augmentation is experimental/investigational.

Yes, the health plan should cover the Linx procedure.
Magnetic sphincter augmentation should be covered for this patient.  There are good data supporting the use of magnetic sphincter augmentation for medically refractory GERD (gastroesophageal reflux disease) (see references).  Thus, this procedure can no longer be considered experimental/investigational.  Additionally, major foregut societies recommend its use, as outlined below:

Sages technology and value assessment committee "safety and effectiveness analysis of the LINX reflux management system posted": "The LINX device has been demonstrated to result in long-term GERD [gastroesophageal reflux disease] control based on symptomatic outcomes, PPI [proton pump inhibitor] utilization, and pH [potential of hydrogen] studies," and, "should be covered and reimbursed by insurance for appropriate patients."

ASGS (American Society of General Surgeons) "LINX statement in support from ASGS [American Society of General Surgeons]" : "based on currently available information and the experience of her members with the procedure, we do support the LINX procedure as a mechanism for controlling GERD [gastroesophageal reflux disease] when it is placed by properly trained laparoscopic surgeons with experience in foregut surgery in the management of GERD [gastroesophageal reflux disease] patients."

Yes, the requested Linx procedure is superior to PPI (proton pump inhibitors) in controlling medically refractory regurgitation symptoms (see references).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure

Treatment: Hospital admission 

The insurer denied coverage for hospital admission.

The denial is upheld. 

This female patient has a history of peripartum cardiomyopathy, obesity, former smoker, and congestive heart failure (CHF).

The patient was admitted with symptoms of congestive heart failure. The patient's care could have been rendered under observational status. There was evidence clinically and radiographically of congestive heart failure, which supported observational care. Inpatient admission status was not met due to lack of severity of disease or comorbidities. There was no evidence of myocardial ischemia, hemodynamic instability, electrolyte abnormalities, hypoxemia, or other indications to substantiate medical necessity for acute inpatient admission status for the dates under review. Per Milliman Care Guideline (MCG) 24th Edition - Heart Failure: Observation Care, the patient's care could have been provided under observational level of care.

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

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

Diagnosis: Superimposed cellulitis

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld. 

This male patient has a history of morbid obesity, diabetes mellitus, hypertension, atrial fibrillation, chronic venous insufficiency, obstructive sleep apnea, and depression.

The patient was started empirically on intravenous (IV) antibiotics (Vancomycin and cefepime) for possible lower extremity cellulitis. X-ray of the leg was negative for any bone destruction. Duplex doppler was negative for deep vein thrombosis (DVT). Infectious Diseases consulted and recommended discontinuation of antibiotics since there were no further signs of infection. The patient had a fall during his hospital stay and imaging studies were negative. He remained afebrile, as well as clinically and hemodynamically stable. The patient refused subacute rehabilitation transfer and he was discharged to continue outpatient follow-up.

According to documentation, the patient presented with possible acute on chronic lower extremity cellulitis. Otherwise, he remained afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal white blood cell count. Progress notes describe chronic lymphedema due to underlying morbid obesity and poor self-care. In fact, Infectious Diseases recommended discontinuation of antibiotics. Based on above findings, the patient met criteria for observation level of management. He did not fulfill criteria for acute hospital admission.

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

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

Diagnosis: Failure to Thrive

Treatment: PDN (private duty nurse) 10 hours per day, 7 days per week

The insurer denied coverage for PDN 10 hours per day, 7 days per week.

The denial is upheld. 

This male patient has a history of gastroesophageal reflux disease (GERD) and failure to thrive. He has difficulty with tolerance of oral feeds and slow growth with signs of improvement over time. According to the records submitted for review, his care consists mostly of monitoring his overall condition that has been stable, administration of infrequent respiratory medications, uncomplicated daytime oral feeds/hydration, custodial care, and proper positioning.

Although there are no swallowing studies submitted for review, this child seems at minimal risk of aspiration with proper precautions. He takes a regular diet and thin liquids by mouth without vomiting, gagging, or choking. There are no reported recurrent pneumonias, impaired oxygenation or frequent deep suctioning that appears mitigated by appropriate precautions. The overall complexity of his current care plan is such that it is reasonable to expect a well-trained non-medical caretaker to provide most of the current allocated care needs without skilled nursing present. This patient will continue to receive monitoring and coaching with the skilled nursing services approved by the insurer.

Given the above factors, this patient's medical condition and care needs do not meet standards for medically necessity for 10 hours of private duty nursing per day. His chronic medical conditions and chronic care needs appear stable and within the family's ability to participate, meriting a reduction in hours of skilled nursing coverage. It appears unlikely that the lower total skilled nursing allocation would create an overwhelming burden on the family or jeopardize this patient's overall health status. Periodic adjustments in this patient's treatment plan will continue to occur guided by his chronic multidisciplinary treatment team. This decision was rendered based on review of the medical record and the criteria for private duty nursing.

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

The carrier's denial of coverage for the PDN 10 hours per day, 7 days per week is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophageal cancer
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with recurrent esophageal cancer.  He had a right video-assisted thoracoscopic surgery (RVATS) and wedge resection with related inpatient stay.  The inpatient stay is under review.

Yes, the inpatient admission was medically necessary.

The inpatient stay was medically necessary as the patient had a right lower lobe wedge resection and lymph node dissection.  The patient needed monitoring of chest tube output and air leak and monitoring for atrial fibrillation.  The patient required intravenous (IV) analgesia to control the pain.  The chest tube was removed and the patient was then discharged home.  The care and monitoring needed were consistent with an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Wegovy 0.25MG/0.5ML SC SOAJ, Pre-service. 

The insurer denied the Wegovy 0.25MG/0.5ML SC SOAJ. 
The denial is overturned. 

This patient is a female diagnosed with obesity. This request is for Wegovy. As reported; the patient has overweight liver cyst; dyslipidemia. She states that she has tried diet and exercise for 12 months without success. As per the prior authorization records; the patient has a documented trial and failure of, intolerance to or a contraindication to ALL appropriate formulary alternatives. 

Yes, the proposed treatment is medically necessary. 

Semaglutide is a glucagon like peptide one receptor (GLP1R) agonist [1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity  [2, [3, [4]. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity [5, [6, [7]. This medication is now available for the treatment of obesity in the form of Wegovy. The request is consistent with generally accepted standards of medical practice. The requested medication is expected to be best interest for the patient. The request is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chest pain.

Treatment: inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.

The denial is overturned. 

This male patient has a history of atrial fibrillation (A-fib), biliary cirrhosis, hypertension, anxiety, major depressive disorder, hypothyroidism, lower extremity lymphedema, morbid obesity, cholecystectomy, and obstructive sleep apnea.

Patients presenting with atrial arrhythmia and ventricular rates up to 130 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for AF (atrial fibrillation) over a fifteen-year period demonstrated an average length of stay of 3 days. (1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted AF. In addition to AF, this patient had a prolonged QT interval on electrocardiogram (ECG) and was treated with sotalol. American Heart Association/ American College of Cardiology (AHA/ACC) Guidelines for the management of atrial fibrillation recommend careful telemetry monitoring for patients treated with class III antiarrhythmic agents as QT prolongation can lead to ventricular arrhythmia and even sudden cardiac death. In conclusion, acute inpatient admission was medically necessary in this case.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.