Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome
Treatment: Oupatient Ambulatory Surgery (MPI) code 37241 x 1
The insurer denied the Oupatient Ambulatory Surgery (MPI) code 37241 x 1
The denial is overturned.

The patient is a female with pelvic congestion syndrome. The request is for ovarian vein embolization.

Yes, the health plan should cover the proposed treatment.

There are no phase I, II, or III clinical trials or determinations of safety in comparison to conventional alternatives or toxicity regarding ovarian and internal iliac vein embolization for pelvic congestion syndrome found by a search at ClinicalTrials.gov. Ovarian and internal iliac vein embolization is a procedure and does not need FDA (United States Food and Drug Administration) approval and also does not require IRB (institutional review board) approval.

A search on PubMed finds many articles concerning the treatment of pelvic congestion syndrome, with the overall conclusion that ovarian and internal iliac vein embolization is efficacious, safe, has been performed for many years, and, along with surgery, is standard-of-care for the treatment of pelvic congestion syndrome (PCS).

A peer-reviewed prospective trial by Kim of 131 patients, found that: "embolotherapy can achieve significant improvement in pain perception levels in patients with chronic pelvic pain caused by pelvic venous congestion."

A prospective study of 56 patients performed by Venbrux, found that: "For patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS [visual analog scale] without any notable impact on menstrual cycle."

A review article states that ovarian vein embolization results are "equivalent to those of surgery and better than conventional medical therapy." Several quotes from other peer-reviewed published review articles state that "[o]varian vein embolization using coils is a safe and effective therapeutic method for treatment of PCS" and "[o]varian and/or internal iliac vein embolization appears to be a safe, well-tolerated, effective treatment for pelvic congestion syndrome."

A retrospective paper of 113 patients by Nasser, found that "Transcatheter embolization was safe and effective for PCS [pelvic congestion syndrome]." A review paper by Smith, states that "Limited clinical evidence supports the use of embolotherapy in the management of pelvic congestion syndrome."
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a G2P1000 (gravidity [pregnancies] two, para [pregnancies to term] one, no preterm pregnancies, no abortions or miscarriages, and no living children) female who presented to the hospital at 29 weeks six days with a complaint of intermittent abdominal pain over the past day.  Her past history was significant for some degree of developmental disability and likely pregestational  diabetes for which metformin had been prescribed.  No acute cause was found for the abdominal pain.  However, there was a concern for a need for admission for diabetic control.  Of note, there were no significant elevations of blood sugar above targets appropriate for pregnancy documented at admission or during the hospital course.  The patient did complain of some hypoglycemic symptoms as an outpatient but there is no documentation of hypoglycemia.  

The patient was admitted for glycemic control although all documented blood sugars are not significantly elevated.  She was also treated for bacteremia although there is no evidence of pyelonephritis or failure of outpatient treatment.  Maternal and fetal echocardiograms were done, Rh incompatibility treatment (RhoGam) and Tetanus Diphtheria and Pertussis (TDAP) vaccine were administered.  The patient was discharged home on hospital day #2.

The health plan contends that the admission was not medically necessary because the labs, test, and glucose monitoring could have been done without need for admission.  The facility contends that the admission was medically necessary due to the severity of the presenting symptomatology coupled with the persistence of symptoms despite initial aggressive management and cites InterQual clinical guidelines.

No, the proposed treatment is not medically necessary.

There was no evidence presented that outpatient management of diabetes resulted in unacceptably high glucose levels compared to standard goals for diabetes in pregnancy.  Upon initial evaluation at the hospital, there was no evidence of blood sugar levels or other complications of diabetes that were life threatening to either the mother or the baby or that would require inpatient management.  The workup that was done in the hospital could be accomplished routinely on an outpatient basis.  In addition, the bacteriuria that was treated intravenously in the hospital could have been treated with oral medications on an outpatient basis or with outpatient administration of parenteral antibiotics.

There was no medical necessity for the admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia and Tardive Dystonia
Treatment: Increase Personal Care Services from 77 Hours per Week TO 24 Hours Split Shift; Total 168 Hours per Week
The insurer denied the Increase Personal Care Services from 77 Hours per Week TO 24 Hours Split Shift; Total 168 Hours per Week
The denial is overturned.

The patient is a female with a history of Alzheimer's dementia and Tardive Dystonia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 24 Hours Split Shift; Total 168 Hours per Week Personal Care Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 24 Hours Split Shift; Total 168 Hours Per Week Personal Assistance Services is deemed medically necessary.

Recent correspondence from the patient's medical provider indicates that due to progressively worsening functional and cognitive decline, the patient is now completely dependent on assistance for completion of her ADLs (activities of daily living). Hence, the currently approved plan of 77 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 24 Hours Split Shift; Total 168 Hours per Week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic breast cancer. 
Treatment: Proton Beam Therapy, Pre-service. 

The insurer denied the Proton Beam Therapy, Pre-service. 
The denial is upheld. 

The patient is a female with metastatic breast cancer to the brain and spine. She is status post palliative radiotherapy to the posterior fossa. She presents with leptomeningeal involvement. She was referred for cranial spinal radiotherapy. 

No, the proton beam therapy is not medically necessary. 

Proton therapy in this patient's case is unproven. Clinical evidence to support the use of proton therapy in this case in terms of safety and efficacy has not been well-established. Peer-reviewed medical articles pertaining to this case to justify the use of proton therapy are limited and retrospective in nature. Standard radiotherapy with photon either 3D (three-dimensional) or IMRT (intensity-modulated radiation therapy) for this case would still be considered the standard approach. Even though technically the proposed treatment is dosimetrically superior than photon therapy, this has not been shown to translate to a clinical advantage. 

There are no unique clinical circumstances that would applicable to this case that would make the use of PBT (proton beam therapy) medically appropriate.  As stated above, PBT (proton beam therapy) is considered unproven for this patient's scenario.  Efficacy, safety and quality of life on the use of PBT (proton beam therapy) for this patient's scenario have not been clinically established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cervical spinal stenosis
Treatment: Personal Care Assistance Service 
The insurer denied Consumer Directed Personal Care Assistance Service to 32 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of major depressive disorder, anxiety, gastroesophageal reflux disease (GERD), cervical spinal stenosis, inflammatory spondylopathy lumbar region, fibromyalgia, constipation, memory loss and urinary incontinence who had been assigned consumer directed personal care assistance services. There was a request to increase consumer directed personal care assistance services and the patient underwent a telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, stairs, and transportation. The patient was assessed at limited assistance with tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility while supervision only with task of eating. Notes from the assessment stated the patient was having forgetfulness, has chronic neck, back and all major joint pain with limited dexterity and joint stiffness. The notes also stated the patient transfers/ambulates with cane/walker, contact assistance. In addition, the assessment notes stated the patient wears panty liners and changed them 5-6 times per day. 

Consumer Directed Personal Care Assistance Service to 32 Hours per Week are medically necessary for this patient.
The patient has documented chronic medical conditions of neck pain, back pain, fibromyalgia, memory loss, and severe depression. The recent assessment tool documented that the patient transfers/ambulates with cane/walker and contact assistance. The patient requires at least limited assistance with all tasks except eating. The plan allotted approximately 10 minutes per day for all toileting and incontinence needs. This amount of time is not sufficient to meet the patient's needs of walking, locomotion, transfer toilet, and toilet use. The patient has no informal helper so the only assistance she receives is when consumer directed personal care assistant is present to assist. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's psychiatrist further documented the decline in the patient's physical and mental functioning. In summary, the summary of hours recommended underestimated the patient's personal care needs on a daily/weekly basis. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, consumer directed personal care assistance services 32 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Mitral Regurgitation. 
Treatment: Heart Procedure (Procedure Codes: 33418 & 33419 - Transcatheter Mitral Valve Replacement). 

The insurer denied the Heart Procedure (Procedure Codes: 33418 & 33419 - Transcatheter Mitral Valve Replacement). 
The denial is overturned. 

The patient is a male with a past medical history significant for hypertension, SLE (systemic lupus erythematosus), anticardiolipin antibodies, multiple prior thrombosis on Coumadin, adrenal insufficiency, coronary artery disease, status post myocardial infarction, ischemic cardiomyopathy, congestive heart failure, status post bi-ventricular pacemaker/defibrillator implantation, severe myocardial infarction. He was referred for transcatheter mitral valve repair with MitraClip device. 

Yes, the health plan should cover the Transcatheter Mitral Valve Replacement. 

Yes, the requested therapy is likely to be more beneficial for the enrollee than any available standard therapy. 

The patient has severe ischemic cardiomyopathy with depressed LV (left ventricle) function and functional mitral regurgitation, with symptoms of heart failure, despite optimal medical therapy and bi-ventricular pacemaker implantation. He has a high STS (Society of Thoracic Surgeons) risk score and is at high risk for traditional open heart mitral valve surgery, given his comorbidities. MitraClip has been FDA (United States Food and Drug Administration)-approved for treatment of functional mitral regurgitation based on the results of clinical trials, and has been successfully used in patients such as this one for management of mitral regurgitation. 

As the patient has failed available standard therapy of medical therapy in combination with Bi-ventricular pacing, the use of this device is likely to be more beneficial for the enrollee than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Mitral Regurgitation. 
Treatment: Heart Procedure (Procedure Codes: 33418 & 33419 - Transcatheter Mitral Valve Replacement). 

The insurer denied the Heart Procedure (Procedure Codes: 33418 & 33419 - Transcatheter Mitral Valve Replacement). 
The denial is overturned. 

The patient is a male with symptomatic mitral regurgitation. He has had multiple admissions for CHF (congestive heart failure). He is on advanced medical therapy. He has multiple co-morbidities including CAD (coronary artery disease), MI (myocardial infarction), dissection of LAD (left anterior descending), LV (left ventricle) dysfunction, including LV (left ventricle) dilation and EF (ejection fraction) of 38%, BiV (biventricular) AICD (automatic implantable cardioverter defibrillator). He also has history of adrenal insufficiency, history of thrombosis and on Coumadin, SLE (systemic lupus erythematosus), on immunosuppression. 

Yes, the health plan should cover the Transcatheter Mitral Valve Replacement. 

TMVR (Transcatheter Mitral Valve Replacement), specifically MitraClip, has become a standard and accepted therapy throughout the world. Many healthcare systems perform two to three per day at their hospitals. Transcatheter Mitral Valve Replacement is not considered experimental or investigational. It is endorsed by ACC (American College of Cardiology), SCAI (Society for Cardiovascular Angiography & Interventions), AATS (American Association for Thoracic Surgery) and will certainly will receive a NDR (national determination for reimbursement). The mitral clip procedure in approved in Europe and performed frequently. 

The patient meets criteria for mitral valve repair due to his symptoms. He is an extremely poor candidate for surgery due to multiple co-morbidities. 

Yes, the Transcatheter Mitral Valve Replacement is likely to be more beneficial. 

The patient is a very high risk for surgical procedures, in particular open heart surgery. The available "standard therapy" is likely to have a worst outcome than a percutaneous MVR (mitral valve replacement).
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Inpatient hospital

Diagnosis: Diarrhea, fever
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented with fever and diarrhea. He was well until 2 days prior to presentation when he developed diarrhea, with up to 2 episodes per day. He also had decreased oral intake, but continued to have normal urinary output. He was spiking fevers every 4 hours, which did not resolve with antipyretics. His temperature went up to 104F at home.

In the emergency department, he had a fever of 39.9C and a pulse of 166 beats per minute (bpm). He was noted to have crying with a minimal amount of tears and dry mucous membranes. His capillary refill was 2-3 seconds. He also had erythema of his posterior pharynx.

The inpatient hospitalization admission was medically necessary for this patient. He required hospitalization admission due to dehydration, the need for intravenous fluids, and the need for close monitoring with very high fever while cultures were pending. In fact, he continued to have high fever during his admission, and continued to have requirement for intravenous fluid supplementation.

Intravenous fluids are required for children with diarrhea who are unable to keep up with the demands for oral rehydration therapy. This patient had increased fluid losses, both through his diarrhea and through insensible losses with high fever. Importantly, young children are more susceptible to dehydration than older children because they have a higher body surface-to-volume ratio, a higher metabolic rate, and lower fluid reserves.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The case involves a man with a history of chronic obstructive pulmonary disease (COPD), chronic tobacco abuse, chronic alcohol use, and hyperlipidemia, who presented to the hospital after being brought in by medics due to persistent shortness of breath and chest tightness. Symptoms had progressively worsened and therefore he presented to the hospital. He was recently evaluated in the emergency room (ER) for similar symptoms and prescribed azithromycin; however, did not pick up and start this medication apparently because of ongoing alcohol consumption. On presentation to the emergency room, he had bilateral wheezing on examination. He had an elevated blood alcohol level measuring 61 milligrams (mg) per decilitre (dL). Chest x-ray showed prominent emphysema and scarring in the right upper lobe extending into the apex and opacity overlying the right hard border and right middle lobe. He received intravenous dexamethasone, albuterol / ipratropium (duoneb) treatment. Despite these interventions, he continued to have severe persistent wheezing and therefore was recommended for acute inpatient admission and care. The recommendation was for management of severe, persistent shortness of breath, wheezing, chest tightness, due to acute exacerbation of COPD secondary to possible lobar pneumonia. 

The inpatient admission was medically necessary.
Inpatient admission was medically necessary due to an exacerbation of underlying COPD which was unresponsive to initial medical therapies including intravenous (IV) corticosteroids, multiple bronchodilator nebulized treatments. The treatment the patient received for acute exacerbation of COPD was compliant with current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Per the GOLD guidelines, hospital admission for COPD should occur if there is failure of exacerbation to respond to initial medical management. The patient had received three treatments with bronchodilator nebulizer treatments in the emergency room as well as IV steroids (IV dexamethasone) and despite these treatments he continued to have symptoms of shortness of breath and audible significant wheezing on exam. Therefore, outpatient treatment would not have been appropriate given his failure to respond to initial aggressive medical management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

This male patient presented to the emergency department complaining of chest pain and palpitations. His blood pressure was 136/90 millimeters of mercury (mmHg) with a heart rate of 136 beats/minute. His room air oxygen saturation was 99%. An electrocardiogram showed atrial flutter with a rapid ventricular rate. The patient was treated with intravenous diltiazem and admitted to the hospital. His symptoms resolved with slowing of his heart rate. Later that day a transesophageal electrocardiogram was performed and showed no evidence of left atrial thrombus. The patient's rhythm was electrically cardioverted to sinus. The procedure was uncomplicated. He remained in sinus rhythm and was discharged. Medical necessity for an inpatient admission is at issue.

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

This patient presented with atrial flutter. He was hemodynamically stable, there was no evidence of myocardial ischemia, he was not in decompensated heart failure, had no evidence of structural heart disease and was not at high short-term risk for thromboembolism. His rhythm was electrically converted to sinus within hours of his presentation, and he remained in sinus rhythm after cardioversion. For patients presenting with acute atrial fibrillation (AF) or flutter, the safety of discharge to home with close follow-up has been well demonstrated. As stated by Lin et al., "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. 

Based on the medical records provided an inpatient level of care was not medically necessary in this instance. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Duchenne muscular dystrophy.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Emflaza 6mg tablet. 
The denial is overturned. 

The patient is a male who has been diagnosed with Duchenne muscular dystrophy (DMD), due to duplication of exons 53-57. Records reviewed included letters by his treating neuromuscular specialist and neuromuscular clinic notes, together with an echocardiogram (ECHO) and pulmonary function tests. His medications comprise Emflaza 6 milligrams (mg) tablets, 4 daily, famotidine, enalapril, vitamin D3 and melatonin as needed for sleep. The subject under review is the medical necessity for Emflaza.

The health plan's determination is overturned.

The requested health treatment of Emflaza 6 MG Tablet is medically necessary for this patient. The medical literature supports (Emflaza) deflazacort as being more effective in the treatment of Duchenne muscular dystrophy, with the likelihood of fewer side effects.
In 2016 the American Academy of Neurology issued a practice guideline update summary regarding corticosteroid treatment of Duchenne muscular dystrophy [1]. The authors concluded that "Prednisone 0.75 milligrams per kilogram per day (mg/kg/d) has significant benefit in DMD management and should be considered the optimal prednisone dose. Prednisone 10 mg/kg/weekend is equally effective over a 12-month period, although long-term outcomes of this alternate regimen remain to be seen." Prednisone is not specifically Food and Drug Administration (FDA)-approved for the treatment of DMD.

Continued treatment with deflazacort is medically necessary for this patient. Suddenly stopping the medication and replacing it with an equivalent dose of prednisone puts him at risk for the development of acute myocarditis, which is life-threatening. In addition, deflazacort has shown significant decrease in functional decline compared with prednisone. and is associated with a lower risk of scoliosis, greater percentage lean body mass, and lower weight.