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

Diagnosis: History of Hypertension, Hyperlipidemia, Diabetes Mellitus, Cervicalgia, Osteoporosis and Depression. 
Treatment: Personal Care Aide - five days, five hours, and two days, four hours, total 33 hours per week
The insurer denied the Personal Care Aide - five days, five hours, and two days, four hours, total 33 hours per week. 
The denial is overturned. 

Beneficiary is a female with a history of Hypertension, Hyperlipidemia, Diabetes Mellitus, Cervicalgia, Osteoporosis and Depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 33 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of 33 hours per week Personal Assistance Services is deemed medically necessary. 

This is a female with a history of hypertension, hyperlipidemia, diabetes mellitus, cervicalgia, osteoporosis and depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation was received from the patient's physician, which indicates that due to worsening functional decline secondary to worsening of her conditions of hypertension, hyperlipidemia, diabetes mellitus, cervicalgia, osteoporosis and depression, the currently approved plan of 23 hours per week is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 33 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation
Treatment: Inpatient Stay
The health plan denied the inpatient stay. 
The health plan's determination is overturned.

This case involves a woman with a history of hypertension and Crohn's disease who presented to the emergency room (ER) with palpitations and dizziness due to new onset atrial fibrillation (AFIB) with rapid ventricular response. The patient was given two intravenous (IV) boluses of Diltiazem, IV Heparin, and IV fluids. She was subsequently transferred to another hospital for a higher level of care. Records show that she converted to sinus rhythm in route to the accepting hospital. The patient was admitted for further evaluation and monitoring of new onset atrial fibrillation, labs were checked to rule out myocardial infarction, cardiology was consulted, and potassium was repleted. She was maintained on IV Heparin to prevent stroke. An electrocardiogram (EKG) showed significant ST depression during AFIB with a rapid ventricular response (RVR). At discharge her anticoagulation was changed to Apixaban. The patient's health plan has denied coverage for inpatient level of care due to the lack of medical necessity.

The health plan's determination is overturned, in whole.

The patient's medical team appropriately admitted the patient under inpatient level of care given the need for anticoagulation monitoring, and monitoring on telemetry for AFIB recurrence and bradycardia with Cardizem due to patient's recent history of bradycardia prompting discontinuation of beta-blocker therapy. For these reasons, inpatient level of care was medically appropriate and necessary and in the best interest for the safety of this patient. The patient was appropriately treated according to evidence-based expert consensus guidelines on the management of atrial fibrillation resulting in optimal patient care and outcome (1, 2).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nonalcoholic Steatohepatitis and Mass/Lesion in the Liver
Treatment: Magnetic Resonance Imaging (MRI) of the Abdomen
The insurer denied the Magnetic Resonance Imaging (MRI) of the Abdomen.
The determination is overturned.
The patient has a medical history of nonalcoholic steatohepatitis. She was found to have a liver mass, which has been considered to likely be a focal nodular hyperplasia. Since then, she has developed type 2 diabetes mellitus, epigastric pain, and gastroesophageal reflux disease (GERD). An esophagogastroduodenoscopy showed mild chronic gastritis. She has a history of a prior adverse reaction to iodinated contrast media and to shellfish. She was noted to have a relatively precipitous presentation of probable type 2 diabetes mellitus with neuropathy without a longstanding prior history of impaired fasting glucose or other known risk factors, and a history of nonalcoholic steatohepatitis and hepatic mass likely due to focal nodular hyperplasia; magnetic resonance imaging of the abdomen was ordered, given a contrast allergy with a computed tomography scan, as a follow-up for steatohepatitis and to assess focal nodular hyperplasia of the liver, assess for liver mass or lesion, and to exclude a pancreatic lesion or mass given new diabetes mellitus. Magnetic resonance imaging showed an indeterminate hepatic lesion not typical for a hemangioma or focal nodular hyperplasia, diffuse hepatic steatosis with an elevated hepatic proton density fat fraction of 13%, known cirrhotic configuration of the liver, and beading and irregularity of the right renal artery including the superior branch which can be seen in the setting of fibromuscular dysplasia. At issue is whether the magnetic resonance imaging of the abdomen was likely to be more beneficial than standard treatment(s).
Guidelines from the American College of Radiology recommend magnetic resonance imaging of the liver for evaluation of fat in nonalcoholic steatohepatitis, which the patient has [1]. Additionally, these guidelines recommend magnetic resonance imaging as indicated for evaluation of focal hepatic lesions such as focal nodular hyperplasia, which the patient was reported to have [1]. Finally, the patient had new-onset diabetes mellitus, which can be a sign of pancreatic malignancy, and magnetic resonance imaging is more sensitive than computed tomography scan for the diagnosis of pancreatic cancer; additionally, the patient has a contrast allergy with computed tomography scans [2-6].
For these reasons, the use of magnetic resonance imaging is supported as more beneficial than any standard treatment for the evaluation of this patient's condition.

The health plan's determination is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nonalcoholic Steatohepatitis and Mass/Lesion in the Liver
Treatment: Magnetic Resonance Imaging (MRI) of the Abdomen
The insurer denied the Magnetic Resonance Imaging (MRI) of the Abdomen.
The determination is overturned.

The patient is under evaluation for abnormal radiographic findings. She was  noted to have a lesion in the liver that was thought to be focal nodular hyperplasia. The patient also has a liver diagnoses of non-alcoholic steatohepatitis (NASH). She underwent magnetic resonance imaging (MRI) of the abdomen while undergoing a work up (w/u) for epigastric pain - found to have an indeterminate 1.7 cm lesion in Segment 7 of the liver and diffuse hepatic steatosis. This was performed after an esophagogastroduodenoscopy (EGD) was unrevealing. The lesion in the liver is not consistent with an hemangioma or focal nodular hyperplasia. The pancreas appeared normal. It was suggested the patient undergo a repeat MRI to assess the liver and to rule out a pancreatic lesion in the setting of new onset diabetes. The patient is allergic to intravenous (IV) contrast and therefore MRI was chosen over a computed tomography (CT) scan.
At issue is whether the MRI of the abdomen was likely to be more beneficial than standard treatment(s).
Question(s):
1)  Is/was the proposed health service or treatment Magnetic Resonance Imaging (MRI) of the Abdomen likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease?
Yes. The MRI was likely to be more beneficial than standard treatment(s).
The patient has a solid lesion in the liver which is not consistent with a focal nodular hyperplasia. With the patient's history of epigastric pain, new onset diabetes and a history of a "liver lesion" it was reasonable to perform cross-sectional imaging. The detail provided by an ultrasound would be inadequate and she had a contraindication to intravenous (IV) dye for a CT scan.  National guidelines are addressed in the reference by Marrero JA, Ahn J, Rajender Reddy K, listed below. (1) The manuscript by Venkatesh SK,Chandan V, Roberts LR, referenced below, is a highly quoted review from a premier journal which supports the determination. Both reviews came out around the same time and I am not aware of any changes in national guidelines/recommendations over the past 5 years. Magnetic Resonance Imaging of the Abdomen was likely to be more beneficial than standard treatment for the insured's condition.
2)  Do you uphold or overturn, in whole or in part, the health plan's determination regarding the proposed health service or treatment?
The determination is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic kidney disease and diabetic neuropathy.
Treatment:  Pregabalin 75 milligrams OR CAPS (oral capsules).

The insurer denied the Pregabalin 75 milligrams OR CAPS.  The denial is overturned. 

This is a female with chronic kidney disease and diabetic neuropathy.  She has tried and was intolerant to gabapentin due to confusion.

Yes, the proposed pregabalin is medically necessary.

This patient has experienced confusion with taking gabapentin.  This is documented in the patient's allergy list that was submitted.  This request for pregabalin is for a Food and Drug Administration (FDA) approved indication, and the use of pregabalin in this clinical situation is supported by the American Diabetes Association's clinical guidelines.  Without pregabalin, this patient will have untreated diabetic neuropathic pain.  Therefore, the proposed pregabalin is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation with Rapid Ventricular Rate.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient was referred to the emergency department (ED) from his physician's office. He was complaining of five days of dyspnea. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. His medical history was remarkable for chronic obstructive pulmonary disease (COPD), nonischemic cardiomyopathy, heart failure with reduced ejection fraction, implantable cardioverter defibrillator (ICD), hypertension, and prior polysubstance abuse. In the emergency department, his blood pressure was 133/81 millimeters of mercury (mmHg) with a heart rate of 96 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 96%. His physical exam was remarkable for obesity, wheezing, rales and lower extremity edema, worse on the left, and a rapid, irregular heart rate. An electrocardiogram showed atrial fibrillation with a ventricular rate of 120 beats/minute. The patient's serum troponin level was elevated at .05 nanograms/milliliter (ng/ml). His brain (or B-type) natriuretic peptide (BNP) level was 1,074 picograms per milliliter (pg/ml). A chest x-ray showed cardiomegaly and changes consistent with COPD; there was no acute pathology. A left lower extremity venous Doppler was normal. He was treated with intravenous diltiazem and admitted to the hospital. A repeat troponin level was .03 ng/ml. Intravenous furosemide was administered for heart failure. The patient's chest was clear; he had trace lower extremity edema. The diltiazem infusion was discontinued and oral metoprolol was started. There were 24 episodes where the device sensed ventricular tachycardia due to rapid heart rates; the rate slowed before therapies were delivered. The patient's heart rate was controlled on oral metoprolol and he was discharged. The medical necessity of an inpatient admission is at issue.

Yes. An inpatient stay was medically necessary.
This patient presented with atrial fibrillation and decompensated heart failure. Interrogation of his implantable cardioverter defibrillator (ICD) showed that the patient had been in atrial fibrillation and, during that time, there were two dozen episodes where his heart rate exceeded the ventricular tachycardia rate cut-off of the device. Careful and continuous monitoring with infusion of intravenous diltiazem was required for rate control in order to prevent spurious ICD discharges. Such discharges are uncomfortable for the patient, potentially psychologically damaging and, especially in the case of multiple discharges, can result in hemodynamic deterioration and have been associated with increased mortality. The medical literature supports inpatient admission in this instance given the risk for spurious ICD shocks and adverse outcomes thereof.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope, Chest pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a male patient with a past medical history notable for Wolff-Parkinson-White (WPW) syndrome status post ablation and loop recorder. The patient presented to Emergency Department (ED) with complaints of chest pain, palpitations and a witnessed syncopal episode. The patient reported syncopal episode the prior day as well and was admitted to an outside hospital but left as he reported feeling better. The patient stated that he had been having syncopal episodes more frequently recently. The patient had not been following with a cardiologist. In the ED, patient's vital signs and physical examination were unremarkable. The patient's chest electromagnetic radiation (x-ray) test was normal. The patient's left knee x-ray showed no acute displaced fracture. The patient's electrocardiogram (EKG) showed normal sinus rhythm. The patient's lab studies were notable for an alcohol level of 146. The patient received 1 liter (L) normal saline intravenous (IV) and oral aspirin for left knee pain. The patient was admitted to the Telemetry unit for further evaluation and management of syncope and chest pain. It was noted that before all medical workup, the patient left the facility against medical advice (AMA) the day after admission.   

Based on the review of the medical record and literature, the acute inpatient admission was not medically necessary. The patient presented with a syncopal event. The patient's symptoms were treated and stabilized in the Emergency Department (ED). Due to no other comorbidities or complications, the patient's care could have been rendered in the ED with close follow-up upon discharge. There were no high-risk electrocardiogram (EKG) findings or elevated cardiac biomarkers.  Furthermore, there were no other medical conditions warranting an inpatient admission status, including end-organ dysfunction, cerebrovascular insufficiency, or hemodynamic instability. The patient's clinical presentation did not meet the clinical guidelines for hospital admission. The patient could have been further evaluated at an observational level of care if needed. Thus, inpatient hospital admission was not medically necessary for this patient. 

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

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

Central Nervous System
Home Health Care

Diagnosis: Dementia, CVA
Treatment: Increase in Personal Care Service Hours 
The insurer denied the Increase in Personal Care Service Hours. The health plan's determination is overturned.

The patient is a male with past medical history of hypertension, hyperlipidemia, dementia, cerebrovascular accident (CVA), bladder and bowel incontinence who had been assigned 91 hours/week of personal care assistant (PCA) service hours. He lives with his son and wife who both work. The patient switched insurance and had telephonic assessment tool documenting total assistance for tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, locomotion and toilet use. There was notation that activities of walking and transfer toilet did not occur. The patient was assessed at maximal assistance for task of eating and extensive assistance with task of bed mobility. 

The Increase in Personal Care Service Hours is medically necessary for this patient. The medical records document that the patient is immobile, unable to reposition, unable to feed himself, does not ambulate and has difficulty even moving his legs. The patient's informal caregivers are not able to provide more than 10 hours of care per day. The patient's PCA services are not solely for supervision and safety but to assist patient in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's primary care physician (PCP) notes that the increased home care services are medically necessary for this patient. The assessment performed via telephone indicated that the patient was total assistance for all tasks except for bed mobility and eating. An activity of walking and transferring toilet did not occur as noted in the telephonic assessment but would've been estimated as total assistance. There was an under estimation of his assistant needs for bed mobility and eating on his telephonic assessment. Therefore, the increase in personal care services is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic respiratory failure; Severe restrictive lung disease; Obstructive sleep apnea (OSA).
Treatment: A second ventilator.
The insurer denied coverage for a second ventilator.
The denial is upheld.

This is a female patient who was recommended to receive a non-invasive volume ventilator. The patient has a diagnosis of chronic respiratory failure as well as severe restrictive lung disease due to spina bifida, scoliosis, obstructive sleep apnea (OSA), and gastroesophageal reflux disease. Documentation indicated that the patient has a history of intubation due to forced vital capacity (FVC) of only 6%. The patient had been on bi-level positive airway pressure (BiPAP) at home prior to requiring intubation. The patient was then placed on non-invasive volume ventilation after extubation and was discharged home. The documentation indicated that the patient has no ventilator-free time requiring 2 volume ventilators, which includes one at the bedside and one for the wheelchair. Documentation indicated that continuous positive airway pressure (CPAP) is contraindicated for this patient, given her neuromuscular disease. BiPAP has been trialed and failed, sending the patient to the hospital and requiring intubation. It has been recommended that the patient receive a second ventilator.
 
In this case, the request is for a second ventilator. Duplicate equipment is not considered medically necessary, and more than one Durable Medical Equipment (DME) used for the same or similar function is considered a matter of convenience for the patient and not for medical usage. Therefore, this request for a second ventilator is not medically necessary. 

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

The carrier's denial of coverage for a second ventilator (one for nocturnal use in the bed and one for the wheelchair) should be upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Post Surgical Corneal Ectasia.
Treatment:  Topography-Guided Corneal Collagen Crosslinking.

The insurer denied the Topography-Guided Corneal Collagen Crosslinking.  The denial is overturned. 

The patient is a female.  She underwent Topography-Guided Corneal Collagen Crosslinking on due to post-LASIK (laser-assisted in situ keratomileusis) corneal ectasia causing recurrent corneal erosions and inability to wear contact lenses.  The patient had resulting irregular astigmatism and hyperopia. 

Topography-Guided Corneal Collagen Crosslinking was performed due to post-LASIK corneal ectasia causing recurrent corneal erosions and inability to wear contact lenses. Coverage was denied by the health plan as the procedure was deemed experimental and investigational due to the lack of a "double blind, controlled, randomized clinical trial."

Yes, the health plan should cover the Topography-Guided Corneal Collagen Crosslinking.

The treatment is FDA-approved and, based on the medical records and literature, can reasonably be expected to provide the patient with greater net health benefit than any available standard therapy.

Yes, the Topography-Guided Corneal Collagen Crosslinking is likely to be more beneficial than any standard treatment for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Intracept Procedure [Intraosseous Basivertebral Nerve Ablation]. 

The insurer denied the Intracept Procedure [Intraosseous Basivertebral Nerve Ablation]. 
The health plan's determination is upheld. 

The patient has low back pain and evidence of degenerative disc disease on lumbar magnetic resonance imaging (MRI). The Intracept Procedure (intraosseous basivertebral nerve ablation) is proposed and is under review. 

Based on the submitted clinical material, peer-reviewed medical literature, and standard of care; the Intercept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's disabling condition. 
A prospective randomized double-blind sham-controlled multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain [1], is limited to the primary endpoint of Oswestry Disability Index (ODI) at 3 months; in the intention to treat analysis, there was no statistically significant difference between groups. 
A subsequent publication of the 2-year data from, is limited by a high crossover rate from sham treatment to the active arm at 12 months (treated patients served as their own control); therefore long-term comparative outcomes are unknown. 
An industry sponsored study of ablation of the basivertebral nerve for treatment of back pain, is limited to enrollment of 16 patients without a control arm. 
A prospective, open-label, single-arm, multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain, is limited to the primary endpoint of ODI at 3 months and lack of a control arm. 

Further clinical studies, clinical outcomes research, or clinical trials are necessary to determine the safety, efficacy and anticipated outcomes of the Intercept Procedure as compared with the standard means of treatment of the condition in question.