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

Diagnosis:  Diarrhea and alcohol intoxication.
Treatment:  Inpatient Stay.

The insurer denied the inpatient stay.  The denial was upheld.  

The patient is a  male with a history of alcohol abuse.  He presented with one week of diarrhea and epigastric pain.  The patient states that he was recently diagnosed with C diff. 

The patient was admitted with alcohol intoxication and to monitor for withdrawal.  Plan of care included CIWA (clinical institute withdrawal assessment) protocol.  

This patient was admitted after presenting with alcohol intoxication and impending withdrawal.  The patient was hemodynamically stable.  The patient did not have fever.  He did not have tachycardia.  He did not have vomiting.  He did not have gross tremor.  Labs were remarkable for lactic acidosis.  The patient was admitted with plan for IVF (IV fluids) and CIWA protocol.  There were no signs of alcohol withdrawal.  CIWA protocol remained less than 7.  The patient was clinically stable throughout hospital stay and did not have findings of severe alcohol withdrawal.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope 
Treatment: Inpatient Hospital 

The insurer denied an inpatient hospital stay. The determination is upheld. 

The patient has a past medical history (PMH) of hypertension (HTN), hyperlipidemia (HLPD), peptic ulcer disease (PUD) and coronary artery disease (CAD) status/post (s/p) stents who was admitted with complaints of (c/o) a three-month history of weight loss and dizziness with standing, patient denied bright red blood per rectum (BRBPR). Vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for a hemoglobin of 9.6 and hematocrit 31.7. Radiology studies, a chest x-ray (CXR) showed no acute pathology and a computed tomography (CT) scan of the head showed left temporal encephalomalacia. An electrocardiogram (EKG) showed sinus rhythm. The patient was diagnosed with dizziness secondary to dehydration versus a possible gastrointestinal (GI) bleed. A gastroenterology evaluation noted no overt evidence of an active ongoing GI bleed. The melena was thought most likely secondary to iron supplements, the hemoglobin and hematocrit (H&H) remained stable. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay. 

This patient presented to the ED with c/o dizziness associated with a possible history of melena. The patient was hemodynamically stable, had a stable hemoglobin, did not have persistent orthostasis, there was no evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, BRBPR), coagulopathy, known esophageal varices, or transfusion requirement. In addition, the discharging providers noted that the most likely explanation for the dark stool was iron supplements, not GI bleeding. Overall, this patient received close clinical and biochemical monitoring and was ultimately deemed be unlikely to have a GI bleed, and this work-up could have been safely performed at an observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth 
Treatment: Partial lower denture 

The insurer denied the partial lower denture. The denial is overturned. 

The partial lower denture is medically necessary. 

The patient is missing teeth in both her upper and lower jaws. A partial denture was approved for the upper jaw. This would give her a full complement of teeth on top. She should get a lower partial denture so that she has the same amount of teeth on the lower jaw so that her chewing ability is as much as possible. Without a lower partial denture in place, there will be teeth on top that have nothing to chew against, which is very inefficient. This patient needs a lower partial denture to match her new upper denture for improved mastication. The denture is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Migraine Headaches 
Treatment Occipital Nerve Block. 

The insurer denied the occipital nerve. The determination is upheld. 

The patient has a listed diagnosis of "head pain". Records indicate that she has chronic migraines without aura, with status migrainosus. Other parts of the records, in contradiction, state hemiplegic migraines. There is no evidence of status migrainosus documented. She currently has 10 migraines per month, which is also not compatible with a diagnosis of chronic migraines, which by criteria requires 15 headaches per month. 

It is stated that the patient has failed Imitrex, Relpax, Toradol, Naproxen, Aleve, Advil, acetaminophen, Zomig, as well as both Tylenol with codeine and Fioricet, which are strongly recommended to be avoided in the treatment of migraines given the high risk of rebound headaches. Despite such combined use, no evaluation for rebound headaches is documented. It is stated that she cannot take triptans due to hemiplegic migraines, yet trials of Zomig, Relpax, and Imitrex are reported. Botox is currently used, but no other standard of care migraine prophylactic agents are documented. Gammacore is also currently being used. 

Greater occipital nerve block is requested and is under review as to whether it is likely to be more beneficial than any standard treatment. 

The health plan's determination is upheld. Despite being frequently used for a variety of headaches, there is insufficient evidence from high quality peer reviewed literature, large, well designed, blinded, randomized trials to support long term safety and efficacy of the requested treatment for this patient's condition as described. There is also insufficient evidence that such proposed treatment, if beneficial, would be superior to all currently accepted and recommended treatment options. The proposed treatment is not currently considered standard of care, and it is not a first line recommendation by any specialty guideline that I could identify, given the insufficient evidence mentioned above.
The current standard of care includes evaluation for rebound headaches and avoidance of use of frequent painkillers and any use of opiates or barbiturates as discussed by Langer-Gould et al. Furthermore, standard of care includes prolonged trials of appropriate doses of first line migraine prophylactic agents such as propranolol, timolol, venlafaxine, amitriptyline, valproic acid, topiramate and others. 

Such options must be tried after rebound has been addressed, in proper doses, for prolonged periods of at least 8 weeks, with full adherence, before being considered failures. 

Therefore, standard of care in the treatment of migraines has not been met, according to documentation submitted, and the procedure requested would not be considered likely to be more beneficial than standard treatment. There is insufficient evidence this procedure would be superior to all available options.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Migraine Headaches 
Treatment: Occipital Nerve Block 

The insurer denied the occipital nerve. The determination is upheld. 

The patient has chronic migraines and is currently treated with Botox and GammaCore. Chart notes also indicate that the patient has been treated with gabapentin. At issue is whether greater occipital nerve block is likely to be more beneficial than any standard treatment(s). 

The health plan's determination is upheld. 

The patient has a diagnosis of chronic migraine. Occipital nerve blocks are not recognized as an effective treatment for prevention of chronic migraine. Effective treatments including antidepressants (amitriptyline and other tricyclic antidepressants), anticonvulsants (topiramate and divalproex), and beta-blockers (propranolol). There is no documentation that the patient has tried and failed any of these first-line treatments. Gabapentin is not considered a first-line treatment. Additionally, calcitonin gene-related peptide (CGRP) antagonists are considered second- and third-line therapy for treatment of chronic migraine when oral medications and/or Botox have failed. There is no documentation that the patient has not tried and failed Aimovig and Emgality/Ajovy. These medications have been shown in randomized controlled trials to be effective treatments for chronic migraine. 

Large randomized controlled trials are lacking to show that occipital nerve injections provide sustained relief for migraines. Further studies are needed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Migraine Headaches 
Treatment: Occipital Nerve Block. 

The insurer denied the occipital nerve. The determination is upheld. 

This is a patient with complaints of headaches. Her medical history was noted to be chronic migraine without aura intractable with status migrainosus, hemiplegic migraine with status migrainosus not intractable, and intractable chronic migraine without aura and with status migrainosus. Medications were noted to be Botox every 12 weeks, gabapentin 400 milligrams (mg), Mirena and Apriso. GammaCore (vagus nerve stimulator) was also been prescribed. Examination revealed a normal examination of the cervical spine with full range of motion, no pain on palpation over the bilateral trapezius muscles, pain on palpation over the greater occipital nerve regions, no pain on palpation over the cervical paraspinal muscles or over the master muscles bilaterally, and normal general appearance, head, eye, nose, oral cavity, neck/thyroid, cardiovascular, lung, extremity, cortical function, cranial nerve, motor, reflex, sensory, coordination and gait and station examinations. The diagnosis was chronic migraine without aura intractable with status migrainosus. Occipital, auriculotemporal and supraorbital nerve blocks were recommended and performed on that date. 

It was noted that stress was a trigger for her headaches. Noninvasive vagus nerve stimulation helped but was not covered. She was having 10 headache days per month on Botox and without Botox, the pain was nearly daily. The pain was noted to be moderate to severe intensity associated with nausea and sensitivity to light and sound. Activity, light and sound make the headaches worse. GammaCore was used as needed and resulted in 50% relief for the day. She previously tried and failed Imitrex, Relpax, Toradol, naproxen, Aleve, Advil, Fioricet, acetaminophen, Zomig and Tylenol with codeine. Medications were Botox and Apriso. Her neurological examination remained normal. At issue is whether the requested occipital neve block is likely to be more beneficial than any standard treatment or treatments. 

The health plan's determination is upheld. 

This is a patient with a history of migraines. She has undergone multiple nerve blocks that include occipital, auriculotemporal and supraorbital blocks. She is currently being treated with Botox and had been on multiple medications for migraine abortion and rescue. There is no evidence the peer-reviewed medical literature that occipital nerve blocks are superior to pharmacological management for short-term therapy (rescue) or as a prophylactic medication. There is no evidence that the patient has received any oral migraine prophylactic medication. The only documented prophylactic medication was Botox. Gabapentin is not known to be effective for migraine prophylaxis. As the patient has not had adequate prophylaxis and given the treatment only with rescue or abortive medications (other than Botox), there is no evidence that occipital nerve blocks are superior to any form of oral pharmacological therapy for prophylaxis or for rescue.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment:  Bariatric Surgery  The plan denied bariatric surgery
The health plan's determination is upheld.

This patient has weight related co-morbid conditions include: sleep apnea, hypertension (HTN), and diabetes mellitus (DM). The patient is status/post (s/p) lap band procedure in 2012. An esophagogastroduodenoscopy (EGD) revealed no erosion, gastroesophageal reflux disease (GERD) and gastritis. Additional information, updated dietary and psychological status specifically in regards to gastric bypass, was requested. Additional information was provided and reviewed including a dietary evaluation . A psychological evaluation was not provided. At issue is the medical necessity of bariatric surgery.

The bariatric surgery is not medically necessary based on the information provided. A dietary evaluation was obtained that did not reveal any obvious barriers to surgery. Reoperative bariatric surgery warrants an updated psychological evaluation specifically in regards to the type of surgery and whether the patient is a reasonable candidate, which was not provided for review.

Although this patient is super obese and may benefit from bariatric surgery, medical necessity cannot be determined without an updated psychological evaluation specifically for possible reoperative intervention with conversion to gastric bypass.

The American Society for Metabolic & Bariatric Surgery [ASMBS] (perioperative care) guidelines and the National Institutes of Health (NIH) consensus guidelines and the ASMBS reoperative guidelines recommend that patients who are being considered for treatment of morbid obesity undergo a behavioral/psychological evaluation to ensure that the patient is an appropriate candidate for primary to reoperative bariatric surgery. Gastric bypass has unique risks, such as dumping, changes in ethyl alcohol (ETOH) pharmacokinetics, reactive hypoglycemia and risks from smoking/medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign microscopic hematuria,

Treatment: Cxbladder Detect Gene Expression Test

The insurer denied coverage for Cxbladder Detect Gene Expression Test. The denial is upheld. 

This patient is found to have (benign) microscopic hematuria, and diagnoses of malrotated kidney and urothelial lesion. A Cxbladder test was ordered for the patient; the results showed a Cx bladder detect score of 0.23, which correlated to a high risk of urothelial cancer. 

The Cxbladder detect is a noninvasive, urine-based laboratory test that is based on a bladder cancer molecular signature. It measures the gene expression levels of five MRNA biomarkers that are clinically associated with urothelial cancer. While the most recent NCCN (National Comprehensive Cancer Network) guidelines (2019) states that this urine molecular test may be considered during the surveillance of high-risk, non-muscle, invasive bladder cancer; they note that though these tests have a higher sensitivity for detecting bladder cancer then urine cytology, these tests have lower specificity. 

Thus, urine cytology and cystoscopy remain the gold standard for the detection and screening of bladder cancer. The accuracy of biomarker remains low for low stage tumors, and therefore, cannot be used solely for initial diagnosis or surveillance after primary or initial treatment. Also, all biomarkers still need to be used in combination with other tests to further enhance their effectiveness. Thus, genetic test, such as Cxbladder gene expression test has not been proven effective as a standalone tests or assay. 

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

The carrier's denial of coverage for the Cxbladder Detect Gene Expression Test performed is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fall.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld. 

This patient is a female who presented to the emergency department.  The patient had a past medical history of asthma, seizure, bipolar disorder, and cancer.  She was brought in by emergency medical services (BIBEMS) status post fall versus syncope.  The patient sustained facial abrasions and ecchymosis.  The laboratory work-up was unremarkable.  The CT scan of the head and cervical spine were negative.  The chest x-ray, pelvis x-ray, and left knee x-ray revealed no acute findings.  The patient was cleared by trauma.  It was noted the patient would require admission for further work-up and management of syncopal episodes and that she was unsafe to discharge home.  The admitting diagnosis was a fall.  The patient was noted to be unstable for outpatient management, as she had a fall attributable to her current illness due to her gait instability and generalized weakness.  The patient required frequent vascular checks. 

The physical examination revealed the patient's behavior was normal.  The patient's blood pressure was 164/101 the EKG was normal.  The patient's glucose was 111, RBC was 5.20, and hematocrit was 43.9.  Her venous blood gas PCO2 was 39.7 and PO2 was 59.3.  Her venous oxygen saturation was 91.2%.  The patient's glucose was 110, and her potassium was 5.7.  The sample was noted to be hemolyzed.  The progress notes indicated the patient remembered what had happened.  The patient had fallen many times before.  The patient used a walker at home and a cane outside the home to ambulate.  The patient had no tachycardia, shortness of breath, chest pain, and had normal saturations while on room air.  The patient underwent a consultation with Psychiatry for depression.  The patient was not taking her medications.  The patient was stabilized and was discharged.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The patient was admitted for a fall and syncopal episode. Her neurological examination was normal.  Her CT scan was negative for acute stroke. According to the records, there was no clear evidence of acute change in the patient's neurological examination.  No acute motor, sensory or visual deficit that suggested an acute stroke.  There was no instability, new focal neurological signs, hemodynamic or cardiovascular compromise, or acute prolonged metabolic decompensation, or seizure.  Therefore, the patient's condition did not require acute inpatient care admission.  The inpatient admission was not medically necessary for this patient. 

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

Diagnosis:  GI Bleed
Treatment:  Inpatient stay. 
The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is the case of a female with past medical history of cirrhosis, multiple cecal and hepatic flexure arterial-venous malformations, hypertension, diabetes, and hyperlipidemia, who presented to the emergency department with black stools for the past two weeks with associated shortness of breath even walking just a few steps.  The patient was brought into the hospital with concerns for gastrointestinal bleed in the setting of cirrhosis and known arterial venous malformations, as well and with plans for transfusion, gastroenterology consultation, and close monitoring of fluid overload in the setting of getting transfusion with aortic stenosis and congestive heart failure.

This is a patient who presented with sub-acute on chronic gastrointestinal bleeding. Though her hemoglobin was noted to be 5.8, she was hemodynamically stable on presentation without signs of rapid bleeding, with plans to transfuse, and with gastroenterology assessment that no urgent endoscopy was needed with the patient able to wait three days prior to it being performed.  The patient's hemoglobin subsequently responded appropriately to transfusion; she was not noted to have clear signs of ongoing bleeding, and she remained hemodynamically stable throughout her hospitalization with endoscopy performed three days after presentation that did not reveal an active source of bleeding.  It is unclear why this patient with concerns for acute on chronic bleeding with prior extensive work-up, who was deemed stable enough to wait three days for endoscopy with plans otherwise for transfusion and observation, could not have been safely cared for at a lower level of care.  Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain And High Blood Pressure 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial is upheld. 

The inpatient admission was not medically necessary. 

The patient is a female. She has a past medical history significant for HTN (hypertension), dyslipidemia, diabetes mellitus type II, breast CA (cancer), s/p (status post) lumpectomy, chemotherapy and radiation three years prior. She presented for evaluation in the ER for complaints of chest discomfort for two days duration and elevated blood pressure. 

The patient was found to have elevated BP (blood pressure) on admission at 201/102 mm Hg, which was treated with labetalol and hydralazine. ECG (electrocardiogram) revealed normal sinus rhythm with PAC (premature atrial complexes) and changes consistent with LVH (left ventricular hypertrophy). The cardiac troponin was negative. 

The patient was admitted for monitoring. Cardiology consultation was obtained. A nuclear stress test was recommended and revealed no perfusion defects. Her nifedipine dose was increased for better control of blood pressure and the patient was discharged home with a plan for outpatient follow-up. 

This patient presented for evaluation of chest pain and hypertension. Her blood pressure was controlled with medical therapy. After initial dose of IV Labetalol, she was maintained on oral therapy. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. Ischemia was ruled out by stress testing. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower than inpatient level of care.