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

Diagnosis: Chest Pain

Treatment hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

The patient is an adult female with a past medical history notable for pulmonary embolism, hypertension, iron deficiency anemia, hyperlipidemia, pericarditis, and coronary artery disease with prior coronary stenting. She presented to the Emergency Department (ED) with complaints of intermittent left-sided chest pain. The pain was 10/10 in intensity and radiated to the bilateral upper extremities and upper back. It was associated with upper extremity paresthesia, palpitations, and dizziness. Upon arrival to the ED, the patient's blood pressure was 178/98. Electrocardiogram (EKG) revealed sinus bradycardia with rate of 50, with no ST-T (intervals on EKG) changes. Chest X-ray was unremarkable. The troponin levels were initially and subsequently negative. She was admitted for monitoring. She ruled out for myocardial infarction. Her pain improved with Tylenol. It was suggested that the patient's pain could be attributed to costochondritis. She was discharged with outpatient cardiology follow-up.

The health plan allows for initial evaluation and subsequent monitoring in the hospital under both inpatient and observational levels of care. 

The patient presented with complaints of chest pain. Her symptoms were concerning for a cardiac etiology. The patient underwent appropriate initial evaluation in the ED, which was unremarkable. This included an unremarkable physical exam, a normal EKG, and negative cardiac troponins. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Cardiac troponins remained negative. For all of these reasons, the request did not meet acute inpatient admission, but rather observational level of care.

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

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

Diagnosis: Cellulitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient has a past medical history significant for bipolar disorder and polysubstance abuse and presented to the emergency department with complaints of right-hand swelling and pain. Vitals on presentation included: Temperature 98.2 Fahrenheit, Blood Pressure 131/60, Pulse 99, Respiratory Rate 20, oxygen (O2) saturation 99% [percent] on Room Air. Laboratory results included the following: white blood cell count (WBC)-15.6, hemoglobin - 14.2, hematocrit - 43.8, creatinine-0.78, glucose-105, sedimentation rate-25, and c- reactive protein - 135.  The patient was admitted with a possible right-hand cellulitis. He was empirically started on intravenous antibiotics (vancomycin and cefazolin). X-ray of the right hand showed soft tissue swelling and no bony pathology. Plastic Surgery consulted and performed an incision & drainage procedure. Wound cultures grew Streptococcus viridans and Eikenella corrodens. Infectious Diseases consulted and switched antibiotics to vancomycin and cefepime. The patient remained afebrile, and hemodynamically stable. He was discharged to continue oral antibiotics (Augmentin) as an outpatient. 

According to the documentation, patient presented with a right-hand cellulitis. Laboratory results showed elevated WBC as well as increased inflammatory markers (ESR [erythrocyte sedimentation rate], CRP [C-reactive protein]). X-ray and MRI [magnetic resonance imaging] findings were consistent with a cellulitis/abscess. Cultures grew Streptococcus viridans and Eikenella corrodens. Based on above findings, hospital admission was medically necessary for administration of intravenous antibiotics and surgical incision & drainage in a high-risk patient.  

Inpatient hospital admission was medically necessary. 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 admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bradycardia.
Treatment: Inpatient admission.
The insurer denied the Inpatient admission.
The denial is overturned.

The patient is an adult male with a past medical history significant for diabetes
mellitus, HTN (hypertension), CAD (coronary artery disease), status post recent
CABG (coronary artery bypass graft), and chronic kidney disease. He presented to
the emergency room with lightheadedness.

The patient was assessed to be bradycardic. His BP (blood pressure) was stable.
Laboratory data was significant for worsening renal dysfunction/acute renal failure
and severe hyperkalemia at 7.2. The patient was also noted to have anemia.

The patient was given IV (intravenous) atropine for bradycardia. His amiodarone
was discontinued. Hyperkalemia was treated with IV (intravenous) calcium, and
subsequently with IV (intravenous) insulin, dextrose, as well as albuterol and
Lokelma. IV (intravenous) hydration was provided and renal function was
monitored. Once his condition improved, the patient was discharged to a SNF
(skilled nursing facility). He had complaint of abdominal distention and had work-up for an ileus.

Yes, the Inpatient admission was medically necessary.

The patient with recent CABG (coronary artery bypass graft) surgery, multiple
comorbidities, presented with symptomatic bradycardia and was found to have
acute renal failure with severe hyperkalemia. Given the degree of hyperkalemia,
associated risk for life-threatening arrhythmias, cardiac co-morbidities and need for
urgent treatment of renal failure, it is consistent with the current standard of care
that this patient be managed in an inpatient setting. Therefore, the inpatient
admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult female, which chest pain and shortness of breath that
started four days prior. She went to ER (emergency room) and reported that her
heart was "out of sync".

The patient's EKG (electrocardiogram) showed no evidence of ischemia. Her
monitor showed drop beats. Her echocardiogram normal. She had no history of
heart disease. Her PMH (past medical history) was positive for COVID 19 and
obesity.

The patient's exam was normal. Her vital signs were stable, without ectopy. She
had no chest pain or symptoms upon admission. She was placed on telemetry, and
cardiac enzymes were ordered. Her lab results were normal. The patient had no
further episodes, and she signed herself out AMA (against medical advice).

No, the inpatient admission was not medically necessary.

The medical care and treatment that this patent received did not require an
inpatient level of care.

Determination of level of care is primarily dependent on the actual care a patient
receives, and whether a higher level of acuity is needed to give this care. This is
best reflected in the presentation, physical exam findings, and laboratory orders
and their results. It is also documented in the medical orders for care.

 In this case, the patient's symptoms were atypical and unlikely to be representative
of acute coronary syndrome. Her exam, including VS (vital signs), were normal,
and her cardiac findings were normal. Her biomarkers and EKG
(electrocardiogram) showed no evidence of acute ischemia. Her CXR (chest x-ray)
was normal. Echocardiogram showed no wall motion abnormality. The physicians'
treatment did not reflect any serious concern about patient's cardiac condition. The
medical orders did not include medical therapy for ACS (acute coronary syndrome)
such as IV (intravenous) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin).

The only cardiac care provided was telemetry, which is frequently performed in a
lower level of care. The patient was admitted for monitoring, and the subsequent
tests and therapy also did not require an inpatient level of care. As such, the
inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Evans syndrome.
Treatment: Retacrit 4000Unit/ML IJ SOLN,  Pre-service.
The insurer denied the Retacrit 4000Unit/ML IJ SOLN,  Pre-service.
The denial is overturned. 

The patient is a male with a history of Evans syndrome, a form of hemolytic anemia and thrombocytopenia. He is being treated with steroids. The provider is recommending treatment with Retacrit.

Yes, the treatment with Retacrit is medically necessary.
Evans syndrome (ES) is a rare hematologic disorder characterized by the development of autoimmune hemolytic anemia (AIHA), idiopathic thrombocytopenia (ITP), and occasionally immune-mediated neutropenia. The acute management of ES (Evans syndrome) often consists of blood product transfusion in addition to high-dose steroids and intravenous immunoglobulin (IVIG). Erythropoietin has been shown to be effective in the treatment of autoimmune anemia. EPO (erythropoietin) therapy was able to increase Hemoglobin levels (median Hemoglobin increase greater than 2 g/dL [grams per deciliter]) in more than 70% of patients, both frontline and in relapsed/refractory chronic disease.

The health plan did not take into account that the patient was on steroids.  The use of erythropoietin would be expected to allow the patient to wean off steroids and avoid the long term complications of steroids. It would therefore be in the best interest of the patient to be treated with erythropoietin at this time.

The patient currently has been on steroids with response in his hemoglobin, which would decrease if the steroids are discontinued. The use of erythropoietin would be expected to allow the patient to wean off steroids and avoid the long term complications of steroids.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept Procedure (22899 and C9752)
The insurer denied the Intracept Procedure (22899 and C9752)
The denial is upheld. 

The patient is a female with low back pain after a slip and fall at a store. She was diagnosed with a L1 (first lumbar spine vertebra) fracture and treated conservatively.  The patient has tried lumbar epidural steroid injections, acupuncture, tramadol, gabapentin, lyrica, cymbalta, lumbar medial branch blocks, sacroilliac joint injections, trigger point injections, and facet joint radiofrequency ablation.

MRI (magnetic resonance imaging) shows stable degenerative changes of the lumbar spine, stable mild anterior wedge deformity of L1 (first lumbar spine vertebra) vertebral body, stable 1.2 cm (centimeters) T2 (second thoracic spine vertebra) hyperintense lesion in the L1 (first lumbar spine vertebra) vertebral body (nonspecific), and intraosseous hemangiomas in the L2 (second lumbar spine vertebra), L4 (fourth lumbar spine vertebra), and L5 (fifth lumbar spine vertebra) vertebral bodies.

No, the health plan should not cover the Intracept procedure for this patient.
A service is considered medically appropriate when it meets the accepted standards of medicine and is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms.  There must be peer-reviewed medical literature based on scientific data that shows a treatment is safe and effective for treating or diagnosing a medical condition.  It must be necessary to meet patients basic health needs and it must be correct for the diagnosis.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

The patient does not meet inclusion and exclusion criteria in the current published studies.  As such, the Health plan should not cover the Intracept procedure for this patient.

No, the requested Intracept procedure is not more beneficial than any standard treatment for the patient's condition or disease.
Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on type 1 or type 2 Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.   The patient does not meet inclusion and exclusion criteria in the current published studies, as per the provided clinical records.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept Procedure (22899 and C9752)
The insurer denied the Intracept Procedure (22899 and C9752)
The denial is upheld. 

The patient is a female with a history of chronic low back pain. Her pain has not responded to epidural steroid injections, SI (sacroiliac) joint injection, TPIs (trigger point injections), PT (physical therapy), acupuncture and pain medication. She has done physical therapy and seen a chiropractor. She has tried various medications. Physical exam shows tenderness on palpation and a positive Patrick's test. An Intracept procedure has been recommended. The procedure was denied as experimental/investigational. This was appealed.

No, the health plan should not cover the Intracept procedure.
The patient is a female with a history of chronic low back pain. She has failed epidural steroid injections. She has done physical therapy and seen a chiropractor. She has tried various medications. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new FDA (United States Food and Drug Administration)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion. Spinal cord stimulation is also an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose.

However, despite the above, this patient is scheduled for a RFA (radiofrequency ablation) for facet mediated pain, and no results are available to the outcome of that procedure. The aforementioned is a common cause of axial low back pain. The patient's pain is axial; there is notation of facet arthropathy on the MRI (magnetic resonance imaging). In addition, no Modic changes are present on the MRI (magnetic resonance imaging) report.  In addition, Modic changes can be present without vertebrogenic back pain.

Therefore, while the Intracept procedure is an FDA (United States Food and Drug Administration) approved procedure that is not experimental/investigational, and is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed.  Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, and given the lack of Modic changes on MRI (magnetic resonance imaging), the requested Intracept procedure should not be a covered treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Gastroesophageal Reflux.
Treatment: Linx (a sphincter augmentation device) system and full hospital admission (procedure code 43284).
The insurer denied coverage for Linx system and full hospital admission (procedure code 43284).
The denial is overturned.

The patient has chronic gastroesophageal reflux. He was on proton pump inhibitor (PPI) therapy but continued to have symptoms. He had a DeMeester score of 45.5

UpToDate has an article titled "Surgical Management of Gastroesophageal reflux in adults." The article reviews magnetic sphincter augmentation with Linx. The Food and Drug Administration (FDA) approved the Linx reflux management system. The Linx system increased the lower esophageal sphincter implantation, significantly, fewer patients reported moderate or severe heartburn, these was less regurgitation, and daily PPI use decreased. Gastroesophageal Reflux Disease (GERD)- related quality of life was reported to have improved.

The scientific literature supports the use of the Linx procedure. It improves health outcomes. The procedure has FDA approval. The patient is a good candidate because he has continued GERD symptoms on PPI therapy with a very high DeMeester score. There are several endoscopic treatments. For GERD; however, this procedure has been shown to be beneficial in patients with continued symptoms on PPI Therapy. The procedure has been determined to be safe and is likely to be more beneficial than any standard therapies and the adverse risks are not increase over those of standard therapy.

The carrier's denial of Linx system and full hospital admission (procedure code 43284) should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: nasopharyngeal cancer

Treatment: Proton Beam Radiation Therapy

The insurer is denied coverage for Proton Beam Radiation Therapy

The denial is overturned. 

This male patient has a history of nasopharyngeal cancer.

Proton beam therapy is medically necessary in this case of nasopharynx cancer needing unilateral neck and primary site radiation.  Nasopharynx target volumes frequently are very close to critical structures (brainstem, lenses, optic pathway), and reducing dose to these and other structures can reduce side effects but also always higher dose to the cancer, which leads to better cancer cure rate.  Proton beam therapy is medically necessary in certain head and neck cancers, according to the National Comprehensive Cancer Network (NCCN) guidelines.  This case meets those conditions for proton therapy.

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 Proton Beam Radiation Therapy is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: congenital myasthenia gravis

Treatment: Firdapse

The insurer is denied coverage for Firdapse

The denial is upheld. 

This male patient has a history of congenital myasthenia gravis.

Firdape is used to treat the symptoms of Lambert-Eaton myasthenic syndrome (LEMS) in adults. LEMS is a disease in which patients have muscle weakness because of a failure of the nerves to transmit electrical impulses to the muscles. For muscles to contract, nerves have to transmit electrical impulses to the muscles through a chemical messenger called acetylcholine. Acetylcholine is released from the nerve endings during a period of 'depolarisation'. The active substance in Firdapse, amifampridine, is a potassium channel blocker, which prevents charged potassium particles from leaving the nerve cells. This prolongs the period of depolarisation, allowing more time for the nerves to release acetylcholine and so stimulate the muscles to contract. This is not supported in the use as indicated in this case. In pediatrics, this is not considered standard of care.

In addition, a search of Pubmed using the terms amifampridine and myasthenic syndrome revealed only 4 publications all of which involved Lambert-Eaton. A search using amifampridine and congenital myasthenic syndrome revealed a single case report. With regard to the submitted article by Logan et al, Amifampridine is not mentioned.

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 Firdapse is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: breast cancer with metastasis to bone and liver.

Treatment: Lynparza.

The insurer is denied coverage for Lynparza.

The denial is upheld. 

This female patient has a history of history of breast cancer with metastasis to bone and liver.

All the drug's use for therapy, including Lymparza can cause adverse reactions. Lymparza for instance is associated with acute myelogenous leukemia (AML).      
Standard of chemotherapy, or hormonal therapy can be used to treat this individual's metastatic breast cancer.  
The individual does not have a BRCA mutation. ATM, CDH1, CHEK2, PALB2, PTEN, STK11, and TP53 are not BRCA mutations. The drug Lynparza (olaparib) is only validated to treat metastatic breast cancer with underlying germline BRCA mutations. This drug has not been shown to be of benefit in other situation or based on a FoundationOne report.  This is not supported by the National Comprehensive Cancer Network (NCCN) criteria.

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 Lynparza is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: facial cellulitis secondary to odontogenic infection

Treatment inpatient stay

The insurer denied coverage for inpatient stay

The denial is upheld

The patient is a male with past medical history significant for pre-diabetes and rheumatoid arthritis who presented to the Emergency Department (ED) with complaints of pain and swelling to right side of his face. Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 167/76, Pulse 66, Respiratory Rate 18, oxygen (O2) saturation 95% [percent] on Room Air. Laboratory values were notable for the following: white blood cell count (WBC)-9.6, hemoglobin (Hgb)-13.4, hematocrit (Hct)-39.2, glucose-104, creatinine-0.78.  The patient was empirically started on intravenous (IV) antibiotics (Unasyn) for facial cellulitis secondary to odontogenic infection. Maxillofacial computed tomography (CT) scan showed a periapical abscess of the right second premolar and diffuse soft tissue stranding to right side of face with lymphadenopathy. Patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics and follow-up with oral maxillofacial surgery (OMFS) as an outpatient. 

According to the documentation, the patient presented with right side facial swelling secondary to dental abscess. Otherwise, he was afebrile, stable hemodynamically with normal WBC. No surgical intervention was required. Based on above findings, the patient met criteria for observation level of management. The documentation does not support need for acute inpatient hospitalization. 

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

The insurer's denial of coverage for the inpatient stay is upheld. Medical necessity is not substantiated.