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

Diagnosis: Bilateral knee pain. 
Treatment: Magnetic resonance imaging (MRI) of the knee. 

The insurer denied coverage for MRI of the knee. 

The denial is upheld. 

This is a patient with a history of Crohn's disease, knee surgery on both knees, and shoulder surgery. She presented to the Sports Medicine physician's office with complaints of bilateral knee pain. She had surgery on both knees a few years prior. She cannot run without pain. She has been unresponsive to years of conservative management. Magnetic resonance imaging (MRI) of both knees was done. 

The records show the patient has chronic knee pains. She had been able to run. She had undergone surgery and reported several months of conservative treatments. She was evaluated with no positive physical findings with the exception of crepitus. There was no documentation regarding recent treatment such as physical therapy, brace, or medication. The MRIs were recommended upon initial evaluation without differential diagnosis, treatment plan nor indication for operative intervention. 

An MRI is beneficial if additional information aids the physician in establishing the pathology. It is completed if conservative treatments have not been beneficial. 

Based upon lack of recent conservative management, there would be no indication for the MRI's as requested on that date. 

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

The insurer's denial of coverage for magnetic resonance imaging (MRI) of the knee is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: Diarrhea.
Treatment: gastrointestinal pathogen panel stool testing.
The insurer denied coverage for gastrointestinal pathogen panel stool testing.
The denial is overturned.

According to medical records, the patient is a male with a past medical history significant for gastroesophageal reflux disease, thrombocytopenia, anxiety disorder, and mild depression who was evaluated by an internal medicine specialist for complaints of diarrhea, lightheadedness, headache, stomach cramps, bloating, and nausea.

At issue is the denial of coverage of gastrointestinal pathogen PCR (polymerase chain reaction) stool panel (bacteria, virus, or other organisms that can cause disease) testing. Advances in PCR technology have led to significant changes in the diagnosis of viral, bacterial, and/or other infectious agents. Since 2014, the FDA (food and drug administration) has approved several GI (gastrointestinal) panels that currently are being utilized for more rapid diagnosis. These panels allow for the detection and identification of up to 20 pathogens in as little as one hour. 

According to the 2017 Infectious Diseases Society of America (IDSA) guidelines on the management of Infectious Diarrhea, regarding what is the optimal specimen (eg, stool, rectal swab, blood) for maximum yield of bacterial, viral, and protozoal organisms (for culture, immunoassay, and molecular testing)? Their recommendation includes "Molecular techniques generally are more sensitive and less dependent than culture on the quality of the specimen."

Based on the above findings, including IDSA (Infectious Diseases Society of America) guidelines, FDA approval, and other studies suggesting gastrointestinal profile stool PCR tests, despite some limitations, are an acceptable and perhaps even cost-effective diagnostic option for patients with chronic diarrhea. 

Prior determination of denial of coverage for gastrointestinal pathogen panel stool testing (bacteria, virus, or other organisms that can cause disease) is reversed.

The scientific literature does support the use of PCR testing before obtaining routine stool culture and examination for ova and parasites. The PCR panel has FDA approval. The patient is a good candidate for this test, and it is the best available treatment. The adverse risks are not increased.

PCR testing is likely to be more beneficial as compared to routine stool cultures and examination for ova and parasites. 

The carrier's denial of gastrointestinal pathogen panel stool testing should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Diarrhea.
Treatment: gastrointestinal pathogen panel stool testing.
The insurer denied coverage for gastrointestinal pathogen panel stool testing.
The denial is upheld.

The patient developed vomiting and diarrhea. The symptoms first started while away on vacation. It was initially felt that he had a virus. He subsequently saw a gastroenterologist who obtained stool PCR (polymerase chain reaction) testing and found that an infection with E. (Escherichia) Coli and Giardia was still present. The physician writes that because his symptoms were re-occurring, it was critical to determine what kind of infection was present. 

An UpToDate article titled "Approach to the adult with acute diarrhea in resource-rich settings" notes that stool testing with stool cultures is a recommended test if a patient continues to have diarrhea for more than 1 week. The article also addresses multi- pathogen molecular panels. It states that a high degree of clinical correlation is necessary when interpreting results of molecular testing since these assays detect genetic material which does not always indicate infection with a viable organism. Any specimens that test positive for a bacterial pathogen on a multiplex molecular panel, should be submitted for confirmatory culture.

This patient had gastrointestinal infections with E Coli and Giardia. Since he was not getting better, he required stool testing to see if an infection was still present. However, obtaining stool for culture and ova and parasites could have been done without the PCR testing. There is no report submitted that the patient had routine stool cultures and ova and parasites during the period of continued symptoms. 

The scientific literature does not support the use of PCR testing before obtaining routine stool culture and examination for ova and parasites. The PCR panel has FDA (food and drug administration) approval. The patient is not a good candidate for this test, and it is not the best available treatment. 

The diagnosis of these infections could have been made with routine culture and examination for ova and parasites. There are no risks involved in doing the PCR testing. 

The physician is correct that it was necessary to determine what type of infection was present. However, doing PCR testing was not more likely to be beneficial as compared to routine stool cultures and examination for ova and parasites. 

The carrier's denial of gastrointestinal pathogen panel stool testing should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Diabetes/Diabetic Ketoacidosis.
Treatment: Inpatient Hospital.
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is overturned.

This is a female with type 1 diabetes, hypertension, and suspected gastroparesis who presented with abdominal pain, nausea, and vomiting. The patient had a heart rate of 126 beats per minute (bpm), a temperature of 99 Fahrenheit, a respiratory rate of 18 per minute, and a blood pressure of 132/92 millimeters of mercury (mmHg), and an oxygen saturation (O2) of 98%. The patient's laboratory values showed a glucose level of 744 milligrams per deciliter (mg/dL), a sodium level of 130, a potassium level of 5.5, a carbon dioxide level of 16, and a creatinine level of 1.27, and a lactate level of 2.1. The patient's electrocardiogram (EKG) showed sinus tachycardia, possible left atrial enlargement, and a possible septal infarct. She was treated with intravenous Dilaudid, Benadryl, Reglan, and Protonix. The patient was also treated with subcutaneous Insulin and intravenous fluids. She developed hypoglycemia and was treated with Dextrose. The patient was treated with intravenous Rocephin for her leukocytosis. She was also treated with intravenous Iron. The patient was evaluated by endocrinology.
At issue is the medical necessity of the inpatient stay.

I overturn, on the whole, the health plan's determination of medical 
necessity.

This patient was admitted with diabetic ketoacidosis with marked hyperglycemia with a glucose level of 744 mg/dL. The patient's condition was complicated by dehydration with persistent vomiting in the setting of probable gastroparesis. Her management was also complicated by ongoing acute abdominal pain requiring evaluation and intravenous pain medications. The treatment of her diabetic ketoacidosis was complicated by significant hypoglycemia (with glucose as low as 23 mg/dL which required treatment and an endocrinology consultation for Insulin dose adjustment. Therefore, the requested inpatient stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoplastic left heart syndrome
Treatment: Private duty nurse [Registered Nurse/ Licensed Practical Nurse (RN/LPN)] hours of 16 hours per day, 7 days per week for a total of 112 hours per week
The insurer denied coverage for Private duty nurse (RN/LPN) hours of 16 hours per day, 7 days per week for a total of 112 hours per week
The denial is overturned.

This is a patient with a history of hypoplastic left heart syndrome status post-surgical intervention with a variety of medical needs requiring home nursing. These needs include supplemental oxygen requirement, feeding through a nasogastric feeding tube, and seizures. The patient's medical advocate has submitted extensive documentation demonstrating a need for home nursing for 16 hours a day.

An increase of private duty nurse (RN/LPN) hours of 16 hours per day, 7 days per week for a total of 112 hours per week is considered medically necessary for this patient. 

The patient has a history of hypoplastic left heart syndrome status post-surgical intervention. The patient's medical needs include supplemental oxygen requirement, feeding through a nasogastric feeding tube, and seizures. The extensive medical needs of this patient require 16 hours/7 day per week of home nursing. The medical records document a need for at least 16 hours a day of home nursing.

Ni, Z. H., Lv, H. T., Ding, S., & Yao, W. Y. (2019), "Caregivers of congenital heart defects (CHD) children experienced significant demands. After the children underwent their CHD operations, the caregivers experienced complex psychological feelings and excessive stress impacting upon their lives. In addition, caregivers constantly adapted their roles with self-fulfillment in caring activities... Conclusions: CHD surgery has a major impact on the emotions and daily lives of children and their caregivers. This study offers a framework for understanding the importance of actively listening to caregivers so coping strategies can be implemented."

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 Private duty nurse [Registered Nurse/ Licensed Practical Nurse (RN/LPN)] hours of 16 hours per day, 7 days per week for a total of 112 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder/Anemia in Chronic Kidney Disease
Treatment: Pharmacy/Prescription Drugs/Retacrit
The health plan denied the requested medication, Retacrit as not medically necessary. The health plan's determination is upheld.

The patient is a female with chronic kidney disease due to diabetes. Labs demonstrated a hemoglobin of  8.6. The ferritin level was 360. The patient previously received 3 iron infusions. Retacrit 40,000 units per dose for anemia was prescribed.
At issue is the medical necessity for the requested medication, Retacrit.

The health plan's determination of medical necessity is upheld, in whole.

Retacrit is not medically necessary for this patient.
According to pharmacy compendia, the maximal Food and Drug Administration (FDA) approved dose of Retacrit for patients with anemia due to chronic kidney disease who are not on dialysis is 50-100 units per kilogram per dose. With the patient weighing 92 kilograms, the requested dose exceeds the maximal FDA approved dose of the medication. Retacrit is not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine. 
Treatment: Sumatriptan-Naproxen Tablets. 

The insurer denied Sumatriptan-Naproxen Tablets. The health plan's determination is upheld. 

The patient is a woman with acute migraines. Treatment with sumatriptan-naproxen tablets is the subject of this review. The drug was denied because the patient had not tried and failed three formulary alternatives. 

A formulary exception is not indicated in this case. All of the formulary alternatives are safe and effective for treatment of migraine and there is not evidence that the patient has exhausted these alternatives. The formulary alternatives include various combinations of non-steroidal anti-inflammatory drugs (NSAIDS) and triptans, Nurtec ODT (oral disintegrating tablet), Ubrelvy, and Zembrace. All of these are either Food and Drug Administration (FDA) approved and compendia supported for treatment of migraine or standard of care for treatment of acute migraine. No medical reason, such as an absolute contraindication to all of the options, is provided as to why the patient cannot try these alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Otezla 30MG (milligrams).
The insurer denied the Otezla 30MG (milligrams).
The denial is overturned.


The patient is a female with psoriasis affecting ten percent of her body surface area including her back, scalp, and both lower extremities.  It is significantly flaring.  She has also developed joint stiffness and joint aches in the hands and feet.  She has tried and failed ultra-potent topical steroids including clobetasol, betamethasone, and calcipotriene.

Yes, the proposed treatment with Otezla is medically necessary.
The current treatment guidelines that are by nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first-line treatments such as topical corticosteroids and calcipotriene followed by typical second-line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, cyclosporine) and newer therapies, such as small molecule drugs and biologics. 

This patient has moderate to severe psoriasis for which systemic therapy is indicated. She is not a candidate for phototherapy due to the location of psoriasis on the scalp.  With psoriasis of the head, phototherapy is not an appropriate option for treatment. Cyclosporine is not a reasonable long-term option for the patient because of the side effect profile which precludes long-term use when other options are available.  Methotrexate has life-threatening side effects and a much more severe side effect profile than Otezla.  In the era of small molecules (Otezla) and biologic therapies for psoriasis, the use of methotrexate, cyclosporine, or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to newer therapies.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has tried and failed multiple ultra-potent topical steroids.  Additionally, she has joint aches and pains, for which topical therapy is not appropriate.  Phototherapy is not appropriate due to the presence of psoriasis in the scalp, which cannot be reached by this mode of treatment. In the era of small molecules (Otezla) and biologic therapies for psoriasis, the use of methotrexate, cyclosporine, or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to newer therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spondylosis and hypertension. 
Treatment: Outpatient procedures (64493 x 2 and 64494 x 2), facet joint injections. 

The insurer denied coverage for outpatient procedures (64493 x 2 and 64494 x 2), facet joint injections. 
 
The denial is upheld. 

According to the documentation submitted, this is a male with a history of spondylosis and hypertension. He presented to the Pain Management practitioner's office to discuss his second insurance denial for facet joint injections. The patient continued to complain of lower back pain. The treating practitioner recommended medial branch blocks to improve pain. 

The insurer has denied coverage for outpatient procedures (64493 x 2 and 64494 x 2), facet joint injections, as not medically necessary. In a Final Adverse Determination letter, they stated that the records do not show that the patient has tried and failed all types of conservative treatment for at least 6 weeks. There must be an exam showing that facet joints are the source of pain. The requested service is denied based on the guideline Facet Joint Intervention. 

His nurse practitioner is appealing. In the summary of the appeal, he stated that the patient has tried and failed well over 6 weeks of treatment at home. He needs a bilateral medial branch block. 
  
The diagnosis of lumbar facet syndrome is one of exclusion. In fact, the Medicare NCD (National coverage determinations) speaks to no other pathology present that could explain the pain. This patient has two herniated discs which are the most probable pain generators. The correct approach is an epidural steroid injection and surgical consultation and if the pain persists, then a trial of medial branch blocks. 

The insurer's denial of coverage for outpatient procedures (64493 x 2 and 64494 x 2), facet joint injections is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Calculus.
Treatment is D4341 deep gum and root cleaning for lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant.
The insurer denied coverage for D4341 deep gum and root cleaning for lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant.
The denial is upheld.

Based on the submitted documentation which includes copies of periodontal charting, panoramic radiograph, and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 3-5 mm (millimeter) generalized periodontal pocketing with focal 7 mm depth readings and bleeding on probing. The recommended treatment was scaling and root planing in all four maxillary and mandibular quadrants. The insurer has denied the service as the information provided does not show evidence of moderate to severe periodontal disease or other clinical or radiographic criteria such as calculus, to justify the services and therefore does not meet clinical criteria to support scaling and root planing. The patient is appealing.

Upon review of the submitted documentation, there is minimal if any loss of alveolar bone height affecting these teeth. The increased pocket depths likely represent pseudo pocketing due to superficial calculus accumulation and poor oral hygiene. There is minimal significant periodontal probing with no periodontal probing over 7 mm in depth. The insurer has correctly applied the clinical criteria in denying scaling and root planing services.

Uphold denial of coverage for D4341 deep gum and root cleaning for lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant as not medically necessary as the clinical and radiographic documentation does not support or substantiate scaling and root planing services.

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

D4341 deep gum and root cleaning for lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant is not considered medically necessary for this patient.

The insurer's denial of coverage for D4341 deep gum and root cleaning for lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Breast Cancer.
Treatment:  Bioimpendance spectroscopy.

The insurer denied Bioimpendance spectroscopy.  The determination is overturned.

The patient was diagnosed with high-grade ductal carcinoma in situ (DCIS) on a screening mammogram. She underwent a diagnostic workup followed by breast conservation surgery and sentinel node biopsy.

For monitoring the development of lymphedema bioimpedance spectroscopy (BIS) was used. This is a method that has increasing evidence showing its benefit in the early detection of lymphedema. Early detection of lymphedema can lead to improved outcomes with early intervention.

At issue is whether the bioimpedance spectroscopy (BIS) is likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.

Several studies show that BIS monitoring is substantially better than standard circumference monitoring. (6)

Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic breast cancer-related lymphedema (BCRL) with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit concerning chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.

BIS monitoring is a superior method of detecting early lymphedema to standard treatments. Chronic lymphedema can be a disabling or even life-threatening condition. Early detection leads to improved outcomes that are beneficial to the patient.

The records note that the patient had 3 lymph nodes removed and also that she suffered from postoperative sepsis due to a breast infection. Both of these increase her risk of developing lymphedema. Numerous clinical studies show that bioimpedance spectroscopy is a useful tool in the early detection of breast cancer surgery-related lymphedema. It is currently approved by Medicare. Early detection of lymphedema can lead to improved patient outcomes.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Breast Cancer.
Treatment:  Bioimpedance spectroscopy.
The insurer denied Bioimpedance spectroscopy.  
The determination is overturned.

The patient has a history of right breast cancer status post (s/p) mastectomy.
At issue is whether bioimpedance spectroscopy is likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.

Bioimpedance spectroscopy is more beneficial than traditional methods of measuring or identifying lymphedema. Traditional methods of measuring or identifying lymphedema such as arm circumference are outdated and tend to identify lymphedema at later stages, whereas bioimpedance spectroscopy allows for the identification of the very start of lymphedema even before significant physical signs may develop.

The key to managing lymphedema is to start early treatment to stabilize and decrease the severe morbidity of lymphedema.

Koelmeyer et al. found that those women who were in the early surveillance group and were able to have lymphedema care significantly earlier than those in the traditional referral group with the aid of bioimpedance studies had lower rates of stage and severity of lymphedema. Significantly more women in the traditional referral group were diagnosed with clinical lymphedema (stage I-III, 39 % versus 14%; probability (P) less than [<] .001) and with greater severity (stage II-III, 24%) compared with those in the early surveillance group (4%).

Clinicians involved in multidisciplinary centers routinely monitor and utilize bioimpedance studies to help initiate early treatment for lymphedema in women who are at high risk for the development of lymphedema.