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

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

The patient is a male with a history of (H/O) alcohol abuse admitted for acute pancreatitis. Imaging earlier in the month demonstrated a pancreatic cyst. The computed tomography (CT) scan from the day before the admission showed acute edematous pancreatitis and possibly developing small pseudocysts. He was admitted the day prior but left against medical advice (AMA) then returned to the hospital for pain management. The patient smokes cigarettes and marijuana and uses a lot of ibuprofen. He is able to tolerate by mouth (PO) and is not having nausea or vomiting. On exam, he is afebrile and not in acute distress. On exam, he is tender in the epigastric region without guarding or rebound. On admission, the patient was started on narcotics for pain relief. He was given lactated ringers. Clinical Institute Withdrawal Assessment (CIWA) = 0.

The inpatient hospital admission was not medically necessary. A lower level of care was appropriate. The Inpatient care was not required as the patient's computed tomography (CT) showed no concerning pancreatic findings such as necrosis or a large fluid collection. The patient did not have severe systemic complications from pancreatitis such as adult respiratory distress syndrome (ARDS). Additionally, the patient was able to take PO without nausea or vomiting. Observation with parenteral narcotics and aggressive intravenous (IV) hydration was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine Headaches.
Treatment: Botox 100 unit vial, 200 units injected every 3 months for one year; 200 hcpcs (Healthcare Common Procedure Coding System) units per dose for a total of 800 hcpcs units and injection of chemical for destruction of facial and neck nerve muscles on both sides of face. 

The insurer denied Botox 100 unit vial, 200 units injected every 3 months for one year; 200 hcpcs units per dose for a total of 800 hcpcs units and injection of chemical for destruction of facial and neck nerve muscles on both sides of face.  The determination is overturned.

The patient has been under the care of a neurologist for a history of chronic migraine headaches. At her baseline she had daily headaches with superimposed migraines "every 3 days". Migraines could last up to 2 days in duration. She is noted to have previously taken topiramate and amitriptyline. She had also been on duloxetine for a concurrent mood disorder. Records provided for review indicated that the patient had a positive response to therapy with Botox. A request has been made for coverage of Botox. At issue is the medical necessity of the requested Botox.

In this case the patient has been prescribed Botox for the prevention of chronic migraine. This is a diagnosis/indication for which the medication is Food and Drug Administration (FDA) approved for use and one for which its use is supported within practice guidelines (Simpson et al.).

The patient is otherwise noted to have trialed medications from other classes for migraine prevention including but not limited to: amitriptyline, topiramate and duloxetine. Medications currently being taken by the patient would preclude a trial of another antidepressant. Her history of asthma otherwise precludes a trial of a beta blocker.

Generally, the use of Botox is reserved for patients who have an inadequate response to oral prophylactic medications from different classes. The records provided for review have otherwise demonstrated that this standard of practice/care has been achieved. Therefore, the use of Botox would be consistent with the generally accepted standards of practice/care at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute pericarditis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 
This patient presented to the hospital complaining of chest pain and dyspnea that woke her from sleep. Evaluation was concerning for ST elevation myocardial infarction (MI) and the patient was transferred to the intensive care unit (ICU) at another hospital. Upon arrival vital signs were stable with blood pressure (BP) 127/85 and pulse 78 beats per minute. Physical examination was within normal limits. 12 lead electrocardiogram revealed normal sinus rhythm with J point elevation in leads I and augmented Vector Left (aVL). Serum troponin levels were within normal limits. Echocardiogram revealed normal wall motion and left ventricular ejection fraction. The patient was diagnosed with pericarditis and transferred out of the ICU to a lower level of care. She was subsequently discharged on non-steroidal anti-inflammatory medications. 

This patient presented with acute pericarditis and not an ST elevation MI. She was hemodynamically stable and had no fever, large pericardial effusion, or tamponade. She was a low-risk case that could have been managed at a lower level of care. Imazio et al studied 300 consecutive patients presenting to the hospital with chest pain and pericarditis. Patients without a history of immunosuppression, myocarditis, large effusion, and were not taking oral anticoagulant therapy were considered low risk and treated as outpatients. The investigators noted that this method was safe and efficacious. (1) This patient did not have an ST elevation MI and had a low pretest probability of coronary artery disease (2).  In conclusion, ICU/inpatient admission was not medically necessary.

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

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

Diagnosis: Fracture of left tibia
Treatment:  Additional Consumer Directed Personal Assistance Services (CDPAS) for a Total of 63 Hours per Week
The insurer denied the  Additional Consumer Directed Personal Assistance Services (CDPAS) for a Total of 63 Hours per Week
The denial is overturned

The patient is a male with a past medical history of anxiety, attention deficit hyperactivity disorder (ADHD) who reportedly has autism. The patient had a recent fracture of his left tibia. He fell of a scooter and ended up with this injury. The patient needed surgery and he is bed bound at this time. He is non weight bearing status on his left leg for approximately 12 weeks. He has left leg immobilizer in place. The patient needs help with all his activities of daily living (ADLs). 

This review is for additional consumer directed personal assistance services for a total of 63 hours per week.

Yes, the proposed increase in consumer directed personal assistance service for a total of 63 hours per week is medically necessary.
The patient had a recent fracture of his left tibia. The patient needed surgery and he is bed bound at this time. He is non weight bearing on his left leg for approximately 12 weeks. The patient needs help with all his activities of daily living (ADLs). The requested increase in hours is medically appropriate. The patient needs additional consumer directed personal assistance services for a total of 63 hours per week.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient had recent surgery and is immobile at this time. He needs help with all his activities of daily living at this time and needs more hours and help.
Appeal type: Medical necessity
Decision: Upheld

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

This patient presented to the ED (emergency department) complaining of chest pain and shortness of breath for a period of several hours. He had no past medical history and was not taking any medications. Upon arrival to the hospital, blood pressure was elevated (184/87 mmHg [millimeters of mercury]) and pulse was 80 beats per minute.  Physical examination revealed no abnormalities. A 12-lead electrocardiogram revealed normal sinus rhythm without ST (interval on electrocardiogram) or T (interval on electrocardiogram) wave abnormality. Serum troponin was not elevated (0.00 ng/ml [nanogram per milliliter]). Echocardiogram revealed preserved LVEF (left ventricular ejection fraction) 55% (percent) without wall motion abnormalities. The patient was scheduled for cardiac catheterization where a 60-70% occlusion of the mid LAD (left anterior descending) was noted and a drug eluting stent was placed. There were no perioperative complications and the patient was discharged several hours after percutaneous intervention.

This patient presented with chest pain and did not have an acute myocardial infarction.  He effectively underwent elective percutaneous revascularization. The procedure was uncomplicated, and a stent was placed in the mid LAD artery. He was subsequently discharged the on the same day as his procedure. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary.  

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

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

Diagnosis: Sciatica, radiculopathy, degenerative disc disease.

Treatment: Outpatient procedure code 64483 x1 and 64484 x 1, pain injections in the spine.

The insurer denied coverage for outpatient procedure code 64483 x1 and 64484 x 1, pain injections in the spine.

The denial is overturned.

This woman has a history of left sided sciatica, radiculopathy, degenerative disc disease, and hypertension. She presented to the Pain Management physician's office for the evaluation of back pain. The patient had intractable lower back pain for six months. She tried pain medications and physical therapy (PT) without improvement. She had a transforaminal epidural steroid injection (ESI). She had a follow up visit where she reported almost no pain.

In a note, the provider stated that the patient reported excellent pain relief after the first lumbar transforaminal epidural injection of steroids. Pain relief lasted for four weeks.

"The interval between injections varies with the steroid preparation used. Because injected methylprednisolone has been reported to remain in situ for approximately 2 weeks, the clinician should consider waiting approximately 2 weeks after the injection to assess the patient's response and to determine if it would likely be beneficial to administer a repeat injection. However, this 2-week interval may be reduced if a different (short-acting) steroid is used or if the clinical scenario warrants an earlier performance of the repeat epidural. In general, however, routine performance of a predetermined fixed number of epidural injections without a clinical reevaluation in between injection procedures should be discouraged." (1)

"Repeat ESI when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using same scale for at least three months. If a patient fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed using a different approach, level and/or medication, if appropriate, with the rationale and medical necessity for the second ESI documented in the medical record." (2)

A second ESI is medically reasonable and 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 outpatient procedure code 64483 x1 and 64484 x 1, pain injections in the spine is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. Ambulatory surgery implantable magnetic esophageal ring (LINX). 
The insurer denied ambulatory surgery implantable magnetic esophageal ring (LINX). 
The denial is overturned. 

This patient is a female (body mass index [BMI] 22 kilograms per square meter [kg/m2]) who sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD) of several years duration. Her symptoms include heartburn, regurgitation and occasional dysphagia. She has been treated with anti-acid medications (Dexilant, Pepcid, Omeprazole), but has refractory symptoms. She has been evaluated for her complaints with the following diagnostics.

Gastric emptying study showed normal gastric emptying. There was no evidence for gastroparesis. Esophagogastroduodenoscopy (EGD) showed an irregular Z-line with normal endoscopic biopsy of the gastroesophageal junction. Contrast upper gastrointestinal (UGI) was performed and showed no hiatal hernia. Esophageal motility was normal. Manometry testing showed adequately preserved motility. There was normal distal contractile integral. pH (potential hydrogen) testing confirmed pathologic esophageal acid exposure with a DeMeester score of 32 (normal less than [<] 14.7).
The treating surgeon has proposed the LINX procedure as treatment of chronic GERD.
The subject under review is whether the proposed procedure is likely to be more beneficial for this patient than standard treatments.

Considering the submitted documentation, the published literature, and the clinical details of this case, the requested LINX procedure is likely to be more beneficial for this patient compared with alternative surgical and non-surgical therapy, is not investigational / experimental (E/I), and is proven safe and effective.
The LINX procedure, approved by the FDA (United States Food and Drug Administration) in 2012, has demonstrated long term efficacy to support that it is as safe and effective as alternative therapy such as traditional fundoplication with improved risk exposure. Therefore, this procedure is not experimental or investigational for carefully selected patients, as in this case, and has been shown to be safe and effective for a patient such as this. This therapy is likely to be more beneficial for this patient compared with alternative surgical and non-surgical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. Ambulatory surgery implantable magnetic esophageal ring (LINX). 
The insurer denied ambulatory surgery implantable magnetic esophageal ring (LINX). 
The denial is upheld.

The patient is a female with a history of symptoms related to her gastrointestinal (GI) tract. These include what is described as occasional dysphagia, nausea, chest pain, constipation, and regurgitation related to reflux. No relief with proton pump inhibitor (PPI) medication therapy is noted. A gastric emptying study is normal. Potential hydrogen (pH) study demonstrates a normal DeMeester score, though a prior DeMeester score was 32, with elevated non-acidic reflux episodes. Esophageal manometry study was within normal limits. An esophagram demonstrates no reflux, normal motility, no hiatal hernia, and no radiologic evidence of esophagitis. Esophagogastroduodenoscopy (EGD) demonstrates a 2 centimeter (cm) hiatal hernia with irregular Zline at 35 cm, and no pathologic evidence of Barrett's or esophagitis. At issue is the proposed LINX procedure as an Ambulatory Surgery for treatment of this patient's reflux and symptoms. The proposed LINX procedure as Ambulatory Surgery is not likely to be more beneficial than standard treatment for this patient's condition. Medication therapy and surgical fundoplication are current standard therapies, and the LINX system has not proven to be more beneficial in effectiveness or safety over a significant period of time for this chronic disease. Additionally, this patient has complex symptoms with overall poor correlation to straightforward GERD, and as such, even less data supports the LINX in her specific case. Serious concerns remain regarding the long term safety of the device from erosion over the longer term, with nearly every author calling for more randomized data.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. Ambulatory surgery implantable magnetic esophageal ring (LINX). 
The insurer denied ambulatory surgery implantable magnetic esophageal ring (LINX). 
The denial is overturned. 

The patient is a female with body mass index (BMI) 21.9 kilograms per square meter (kg/m2) and history of gastroesophageal reflux disease (GERD), not relieved despite medication use. The patient has also had a vague history of mild gastroparesis in the past but had a normal gastric emptying. 24 hour potential hydrogen (pH) study off medication relieved a significantly elevated DeMeester score consistent with GERD. The patient had an esophagogastroduodenoscopy (EGD) with 2 centimeter (cm) hiatal hernia and no evidence of Barrett's esophagus. Esophageal motility was also reported to be normal. The subject under review is whether the LINX procedure is likely to be more beneficial for the patient than any standard treatment.

This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. Exclusions to LINX treatment include age less than (<) 18, pregnancy, metal allergy, body mass index (BMI) greater than (>)35 kg/m2, hiatal hernia (HH) > 3 cm, Barrett's esophagus with dysplasia and esophageal motility disorder. This patient does not document any exclusion to LINX treatment, which is determined to be appropriate for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: secondary infertility.
Treatment: Hysteroscopic Myomectomy Procedure in a hospital setting.
The insurer denied Hysteroscopic Myomectomy Procedure in a hospital setting. 
The health plan's determination is upheld. 

The patient is a female with secondary infertility. On a sonohystogram, she had an intracavitary lesion. She had a hysteroscopic myomectomy on for a uterine fibroid. There were no intraoperative nor postoperative complications. Pathology showed a leiomyoma and chronic endometritis.

The Hysteroscopic Myomectomy Procedure in a hospital setting is not medically necessary for this patient.
The patient is a healthy female without any significant comorbidities. The procedure could have been performed in an outpatient setting without the need for hospital coverage of the procedure. She had no hepatic nor renal disease. She had no pulmonary nor cardiovascular concerns. The patient had a simple, outpatient procedure without significant blood loss nor anesthesia complications. She returned home the same day, and there were no postoperative complications after surgery. This procedure could have been performed in an ambulatory setting or outpatient clinic office with the appropriate equipment. The hospital setting is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I crowding
Treatment: Braces/monthly visits

The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a male with a diagnosis of Class I crowding. His bite is deep. He has multiple impacted supernumerary teeth: one in the region of teeth 21/22, one in the region of teeth 27/28, and another likely one in the region of teeth 6/7. 

Braces and Monthly Visits are medically necessary. Once the impacted teeth are dealt with, the patient is still left with a deep overbite where the lower incisors are contacting the palate of the upper incisors in occlusion. This is a traumatic occlusion. Not only does it have a positive correlation with periodontal disease, but studies also indicate an increased appearance of periodontal radiolucencies on the maxillary incisors. It is believed these periodontal lesions are related to gingival surface injury and food impaction due to the deep bite. Therefore, correcting the patient's malocclusion with orthodontic treatment will create a clinically significant improvement in the patient's periodontal health. Braces/monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Home Health Care
 
The insurer denied increase in consumer directed personal assistance program (CDPAP) services to 31.5 hours per week. 
The denial is upheld.

The patient is a female with a past medical history significant for pemphigus Vulgaris with secondary complications from treatment resulting in osteoporosis, compression fracture, pain, and anxiety symptoms. According to a letter from the patient's medical provider, the patient is currently on disability as a result of her medical conditions. The patient also currently receives 17.5 hours per week of personal assistant services. 
An increase in services was denied by the plan stating that the plan approved 17.5 hours a week of services, 3.5 hours a day 5 days a week for a total of 17.5 hours.
The subject under review is the medical necessity for consumer-directed personal assistance program (CDPAP) services to be increased to 31.5 hours per week.

The health plan's determination is upheld.

The requested health service is not medically necessary for this patient. The patient has mainly chronic pain issues, ambulatory dysfunction, and anxiety issues from her underlying medical condition. This requires services mainly for bathing, ambulation, and toilet transfer along with certain Instrumental activities of daily living (IADLs). Services currently being provided are sufficient to meet the patient's medical needs. She can ambulate with an assistive device independently in her residence. The current allotted hours are sufficient to provide for her medical needs, based upon nursing assessments. A quarter of the time allotted is for meal preparation and cleaning by her mother who is an aide who helps the patient in the afternoon daily and as needed, and also lives in the same residence. There is no service noted as requested that could not be provided in the allotted time. When approving services, there must be demonstrated need for activities of daily living (ADLs) or IADLs beyond observation and/or preventing falls. Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, the aide must be performing a service such as an ADL or IADL to be a covered service. 

Uniform Assessment System (UAS) State of New York was reviewed which noted a total of 22.5 hours a week of services. UAS State of New York prior assessment was also reviewed. Changes showed no significant change from the previous evaluation.