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

Diagnosis: Genetic disease carrier status
Treatment: Genetic Testing
The insurer denied Genetic Testing.
The determination is overturned.

This patient is under consideration for medical necessity of expanded genetic carrier screening.  The patient is of Ashkenazi Jewish heritage and is the father of the baby of his spouse who has already undergone genetic carrier screening that noted positive states for multiple conditions.

The patient is under consideration for expanded genetic carrier screening. Based upon the patient (father of the baby) being of Ashkenazi Jewish heritage, he would be indicated for the performance of the genetic testing in this case. The testing is medically necessary under the American College of Obstetrics and Gynecology.  This would have been medically necessary given his spouse who was carrying their baby was positive for multiple genetic conditions.  Thus, based upon the recommendations of the American College of Obstetrics and Gynecology, this father who is of Ashkenazi Jewish heritage would be recommended for and found to be meeting medical necessity for the carrier testing performed in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse.
Treatment:  Substance Abuse Inpatient Detoxification.

The insurer denied Substance Abuse Inpatient Detoxification.  The health plan's determination is overturned. 

The patient is an adult male who was self-referred and admitted to acute inpatient level services for detoxification and withdrawal management of opioid (heroin) and cannabis and nicotine use disorder. He was using up to 7 bags of heroin daily with a chronic relapsing course since age 36 and using cannabis and tobacco since adolescence, using 8-9 marijuana blunts per day together with 12 (half) pack per day use of tobacco. The patient had experienced severe drug withdrawal symptoms in the past, and he denied inadvertent overdose. He had received detoxification and rehabilitation treatment in the past with relapse.

Substance Abuse Inpatient Detoxification is medically necessary for this patient.
The inpatient services and detoxification treatment and withdrawal management for severe poly-substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance-related disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders. Withdrawal risk was managed with tapering dosages of methadone and monitoring and prn (as needed) medications, as well as the availability of comfort medications and vitamin and nicotine replacement therapy. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition for appropriate rehabilitation substance use disorder treatment. Thus, the patient did require a safe and effective detoxification with inpatient level services and withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse or remain in treatment if detoxification and treatment were attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a history of (h/o) hypertension (HTN), hyperlipidemia (HL), type 2 diabetes mellitus, who was sent to the emergency room (ER) by his primary care physician (or provider) (PCP) due to a hemoglobin (Hb) of 7.5 and mean corpuscular volume (MCV) of 60. He had exertional dyspnea and weakness for the last few weeks. He also complained of a 10-pound (lb) weight loss. He never had a colonoscopy or esophagogastroduodenoscopy (EGD). He did not have black tarry stools. In the ER, he was hemodynamically stable. He was admitted, given a unit of blood and gastroenterology (GI) was consulted. A computed tomography (CT) scan of the abdomen and pelvis without contrast showed ascending colon thickening and possible vertebral metastasis. GI did the colonoscopy and a biopsy was obtained that showed adenocarcinoma of the colon. Cardiac evaluation was obtained. He eventually was discharged with a plan to complete the work up in the outpatient settings. His Hb remained stable. An inpatient admission is under review for medical necessity.
The inpatient stay was not appropriate and not medically necessary for this patient. The patient had moderate anemia from GI blood loss and was symptomatic, but he did not have any active and profuse bleeding, a need for urgent surgical intervention, or hemodynamic instability that would make him a candidate for inpatient admission.
The patient had a gradual loss in his Hb from his colon cancer and was well compensated. He was symptomatic and was appropriately given a unit of blood. He had moderate anemia from slow blood loss that needed investigation as was done, however, this was appropriate to be done at a lower level or care [1]. He had red flag symptoms of colon cancer and this was appropriately investigated. He had oligometastatic disease versus (vs) locally advanced disease. He needed surgical management and needed surgical clearance [2] but this was appropriate to be done in the outpatient setting. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain

Treatment: Intracept procedure for intraosseous ablation of basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumber or sacral

The insurer denied coverage for Intracept procedure for intraosseous ablation of basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumber or sacral

The denial is upheld 

This is an adult who has chronic low back pain. The patient has had physical therapy (PT). The patient has had medial branch blocks and then radiofrequency ablation (RFA) of the medial branch nerves. The patient had a Transforaminal Epidural Steroid injection. Medication trials have included Oxycodone and Tizanidine.  A magnetic resonance imaging (MRI) is noted by the physician to have Modic changes at L (lumbar) 4 and L5.  The request is for RFA of the Basivertebral nerves (BVN) at those levels.

The provider notes lower back pain which radiates to the buttocks and "down both legs at times in the morning and gets better as the day progresses." The MRI report noted diffuse disc bulging at L2-3, L3-4, with mild/moderate spinal canal stenosis. At L4-5 there is disc bulging eccentric to the right, severe narrowing  of the spinal canal.  The right neural foramen is severely narrowed with effacement of the exiting right L4 nerve root.

A repeat MRI read: "Impression: 1. Degenerative disc disease and spondylosis involving lumbar spine producing moderate L23, severe L34 and severe L45 central spinal stenosis. 2. Central L5S (sacral) 1 disc herniation indenting the anterior aspect of thecal sac. 3. 2 centimeters (cm) extradural mass involving the left L5 nerve root in the distal left L5S1 foramen unchanged from prior examination compatible with a left L5 nerve root schwannoma. 4. Moderate bilateral L45 foraminal stenosis." 

Finally the clinical and MRI findings support other etiologies for this patient's symptoms. 

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 Intracept procedure for intraosseous ablation of basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumber or sacral is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy, Diabetes
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a female who presented to the obstetric triage unit from her maternal-fetal medicine appointment due to noncompliant, uncontrolled type 2 diabetes. 
The patient reported no vaginal bleeding, leakage of fluid or contractions. She reported no pelvic pain. She reported good fetal movement. The patient's current management included insulin. There was suspicion of a large for gestational age infant. Her medications included a prenatal vitamin and insulin.  The patient was noted to have had a maternal-fetal medicine ultrasound performed  which noted a singleton intrauterine pregnancy with a vertex presentation and anterior placenta with amniotic fluid index (AFI) 22.96 centimeters (cm). The patient was admitted to the hospital at 35-6/7 weeks with uncontrolled, noncompliant class B diabetes. She was noted to have pre-eclampsia without severe features based on protein. She had a suspected large for gestational age infant with the fetal abdomen being greater than the 99th percentile. Maternal and fetal status were reassuring. The patient was admitted to labor and delivery for glucose optimization to continue her home insulin regimen with carb consistent diet. She was to have point-of-care glucose testing 5 times daily and was going to be on heparin 5000 units twice daily for deep vein thrombosis (DVT) prophylaxis. She was to have repeat pre-eclampsia labs completed with a repeat hemoglobin A1c. A plan was made for a nonstress test to be completed twice daily. A plan was also made for a 37-week delivery.
The patient was admitted to the hospital where she underwent dietary control leading up to her delivery.
At issue is the medical necessity of inpatient hospital admission.
 
The requested inpatient hospital stay was not medically necessary for this patient given a diagnosis of poor control of Class B diabetes.
The patient was noted to have normal blood pressures with the presence of proteinuria and normal hemolysis, elevated liver enzymes and low platelets (HELLP) labs. Fetal testing was reassuring. Macrosomia was noted on ultrasound. The patient was noted to have no evidence of sepsis or systemic inflammatory response syndrome based upon normal vital signs, afebrile status, normal white blood cell count, and normal differential. The patient had no evidence of hemodynamic instability, renal failure. The patient had a normal complete blood count and normal basic metabolic panel. The patient had no evidence of an acute abdomen or surgical abdomen as there was no rebound or guarding present. The patient was noted to be on a diabetic diet during hospitalization with insulin administration with good control of glycemic status. Fetal testing remained reassuring.
In this case, the patient is noted to have a diagnosis of pregestational, Type II Diabetes that was poorly controlled due to a lack of recognition of diagnosis and pregnancy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: over active bladder

Treatment: Botox Solution Reconstituted (SOLR) 100 units

The insurer denied coverage for Botox Solution Reconstituted (SOLR) 100 units

The denial is overturned

This is an adult female with history of over active bladder (OAB). She has tried and failed numerous OAB medications including Oxybutynin, Trospium extended release (ER), Tolterodine ER, Solifenacin, Toviaz, and mybetriq. She chooses to be treated with Botox Solution Reconstituted (SOLR) 100 units for refractory OAB, after discussion with her urologist. The insurer has denied coverage for Botox SOLR as not medically necessary, stating that the patient did not meet their criteria - history of OAB, loss of bladder control, absence of ongoing urinary tract infection, etc.
 
The appeal by the patient's urologist is noted and read in detail. This patient has had a prior Botox injection, and she wants to try it again. She has failed multiple over active bladder (OAB) prescriptions. Bladder Botox injection is Food and Drug Administration (FDA) approved for patients with an inadequate response or intolerance to oral bladder control prescriptions. Botox injection will result in greater than or equal to 50% reduction urge incontinence episodes in 60-75% of patients, and 30-40% of patients will have complete resolution of their urge incontinence.

Botox SOLR 100 units is considered medically necessary for this patient. 

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 Botox SOLR 100 units is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, scoliosis, polyarthritis, stroke with residual hemiparesis, and heart failure
Treatment: Personal Care Assistance Services for a Total of 56 Hours per Week
The insurer denied: Personal Care Assistance Services for a Total of 56 Hours per Week
The denial is upheld.

This is an elderly male patient that has medical conditions that include diabetes, scoliosis, polyarthritis, stroke with residual hemiparesis, and heart failure. He was admitted to the hospital in 9 months ago after dizziness and a fall. He was treated for a urinary tract infection. He was admitted 2 months ago with community acquired pneumonia. The denial of personal care assistance services, a total of 56 hours per week, is being appealed. The patient is currently receiving 35 hours per week. The plan notes that the currently approved hours are sufficient to support personal hygiene, dressing, walking, locomotion, toileting, bed mobility, eating, and bathing. A letter from the Provider reports the patient's general condition has deteriorated and he needs assistance with transfers, bathing, and grooming. A letter from the patient's daughter reports the patient's health has decreased. The patient needs help with all basic needs. The currently approved 35 hours per week cause a hardship. More hours can make a difference with daily routine and living situation.

The requested health service is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic medical conditions. He was hospitalized last year after presyncope associated with a fall and pneumonia. The denial of personal care assistance services, a total of 56 hours per week, is being appealed. The patient is currently receiving 35 hours per week. The plan notes that the currently approved hours are sufficient to support personal hygiene, dressing, walking, locomotion, toileting, bed mobility, eating, and bathing. Appeal statements note that there has been general deterioration in the patient's medical condition. The information provided supports a deterioration in the patient's medical status but does not support a significant deterioration in his functional needs for assistance with activities of daily living. Personal care assistance services are not indicated for safety supervision or when no tasks are being performed. The proposed increase personal care assistance services to 56 hours per week is not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain; right knee pain, left ankle pain
Treatment: ReActiv8 - Peripheral Neurostimulator
The insurer denied: ReActiv8 - Peripheral Neurostimulator
The denial is upheld.

The patient is an adult female with chronic back pain. Implantation of a peripheral nerve stimulator (PNS) has been recommended. Specifically, Reactiv8, which is a multifidus muscle stimulator. She has failed physical therapy home exercise, medications, and injections. Physical exam shows multifidus muscle instability.

The health plan should not cover the requested health service.

The patient is an adult female with chronic back pain. An implantation of a peripheral nerve stimulator (PNS) has been recommended, specifically Reactiv8, which is a multifidus muscle stimulator. She has failed physical therapy, home exercise, medications, and injections. Physical exam shows multifidus muscle instability. The requested procedure is not a commonly accepted treatment for this condition and has not been shown to be effective in the treatment of chronic low back pain as shown by high quality randomized control trials (RCT). There is a randomized controlled trial in the setting of chronic pain following amputation, but not this condition. These pathologies are quite different. Other case reports and observational studies show some benefits in other pain conditions. Other more proven, conventional treatments have been shown to be superior in the literature, such as spinal cord stimulation. Some recent data has shown it may be effective as add on therapy to spinal cord stimulation (SCS), but not as a standalone therapy. Given the lack of data to support an invasive procedure for this type of condition, the requested peripheral nerve stimulator is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain; right knee pain, left ankle pain
Treatment: ReActiv8 - Peripheral Neurostimulator
The insurer denied: ReActiv8 - Peripheral Neurostimulator
The denial is upheld.

The patient is an adult female. She has a history of lower back pain, right knee pain, and left ankle pain that is shooting, throbbing, aching, and cramping. The pain is constant and 
aggravated with standing and walking. Exam demonstrated antalgic gait. There was paravertebral, bilateral lumbar, and facet tenderness and performance tenderness on the right. Diagnoses include muscle wasting and atrophy; lumbar radiculopathy; unilateral primary osteoarthritis, right knee; and myalgia, unspecified site. The plan is for peripheral nerve stimulator.

The health plan should not cover the requested health service.

The requested procedure is considered investigational. Until there is larger evidence to support the procedure, it is not recommended at this time. The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease. Given that the requested procedure is still considered experimental, it is not recommended at this time. There have not been large enough studies that provide efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain; right knee pain, left ankle pain
Treatment: ReActiv8 - Peripheral Neurostimulator
The insurer denied: ReActiv8 - Peripheral Neurostimulator
The denial is upheld.

The patient is an adult female with chronic low back pain as well as right knee and left ankle pain that began several years ago after a fall. Her past treatments include Lidoderm patch, physical therapy, massage, epidural steroid injection, Butrans, topical compound cream, gabapentin, and oxycodone. Magnetic resonance imaging (MRI) of the lumbar spine from last year shows L (lumbar)4-5 disc bulge, central disc protrusion with mild spinal and left neuroforaminal stenosis, and transitional partially sacralized L5 vertebrae. The request for Reactiv8 peripheral stimulator was denied coverage by the health plan as 
experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

There are studies that demonstrate the potential benefit of peripheral nerve stimulation in treatment of low back pain. However, there is insufficient or inconclusive evidence published in peer-reviewed medical literature to evaluate the therapeutic value. There are no well-designed and well-conducted studies. There is inconclusive evidence published in peer-reviewed medical literature that the service improves net health outcomes. The service under consideration is not as beneficial as any established alternatives. Small, published case studies do demonstrate the significance of peripheral stimulation as an innovative approach to treat chronic pain; however, more studies are needed to substantiate its effectiveness and safety. As such the health plan should not cover the requested health service.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Constipation
Treatment: Formulary exception for Motegrity
The insurer denied: Formulary exception for Motegrity
The denial is overturned.

The patient is an adult male with chronic idiopathic constipation. He has failed Linzess and lubiprostone. He has done well on Motegrity. His provider is requesting for the patient to continue with Motegrity.

The health plan should cover the formulary exception for Motegrity.

The patient has chronic idiopathic constipation. He has failed the two formulary preferred agents, Linzess and lubiprostone. Therefore, Linzess and lubiprostone have been ineffective for the 
patient, and the health plan should cover the formulary exception for Motegrity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple fractures back and arm

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is upheld

 
The patient presented to the emergency department after going to urgent care where x-rays showed a left distal radius fracture and an lumbar (L) 1 compression fracture. He fell from a ladder and had been taking over the counter analgesics for his pain. He denies bowel or bladder retention or incontinence. No saddle anesthesia. Voided since accident. No headache, no nausea or vomiting, no speech or vision changes, no neck pain, no numbness in arms or hands, no trouble with coordination or dropping things. Handwriting- texting- typing stable. No falls since. Pain limiting ambulation. Examination found the patient in no acute distress. There is no cervical tenderness, positive thoracic and lumbar tenderness, swollen left wrist/hand with limited supination/pronation secondary to the pain. There is bony tenderness in the medial aspect of the left wrist. No tenderness a left forearm or elbow. He is ambulatory with a steady gait without difficulty since fall. 

Plan for repeat imaging of left hand/wrist/forearm/elbow. Computed tomography (CT) of thoracic and lumbar spine. No red flag symptoms. Pain management. X-ray of the left wrist found a minimally displaced, obliquely oriented fracture of the ulnar aspect of the distal radius. CT showed traumatic L1 superior endplate fracture without any retropulsion of the bone into the spinal canal and thoracic (T)11 traumatic superior endplate fracture without any retropulsion of the bone into the spinal canal. CT of the cervical spine showed no fracture or subluxation. The patient was discussed with neurosurgery, and it was recommended to admit patient for pain control, magnetic resonance imaging (MRI) of thoracic/lumbar spine, every 4 hours neuro checks, deep vein thrombosis (DVT) prophylaxis with heparin twice daily (BID), and post-residual void checks. 

Milliman Care Guidelines (MCG) notes that the criteria for an inpatient admission due to back pain is indicated for 1 or more of the following: Acute neurologic deficit (e.g., cauda equina or conus medullaris syndrome), as indicated by 1 or more of the following: Bowel dysfunction, Bladder dysfunction, Saddle anesthesia, Other neurologic abnormality suggesting spinal cord impingement, Severe pain requiring acute inpatient management Etiology that requires inpatient treatment (e.g., aortic dissection, epidural abscess, spinal instability) identified.

The review of clinical notes did not find a pain score in the documentation. The patient was maintained on Tylenol and Ibuprofen with only one dose of oxycodone on the day of discharge. There were not any acute findings or severe pain reported to indicate the need for an inpatient admission versus observation. 

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 admission is not substantiated.