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

Diagnosis: Syncope. 
Treatment: Wearable mobile cardiovascular telemetry with electrocardiographic recording. 
The insurer denied coverage for wearable mobile cardiovascular telemetry with electrocardiographic recording. 
The denial is upheld. 

This is a patient with a history of recurrent syncope since childhood. Family history was positive for sudden premature death in her baby brother and father. Complete genetic testing for malignant channelopathy was performed and failed to yield any abnormality. She was diagnosed with neural reflex syncope and a dual chamber pacemaker was implanted. She had two episodes of syncope with tonic clonic seizure activity, loss of continence and prolonged post ictal confusion, approximately 2 years prior. Physical exam was without abnormality. Echocardiography revealed a preserved left ventricular ejection fraction (LVEF) without valvular pathology. Pacemaker telemetry check demonstrated no malignant arrhythmia with occasional atrial pacing. A thirty-day real time mobile cardiovascular telemetry monitor was ordered to determine an etiology for syncope. 

This patient suffered from syncope since childhood that was likely secondary to a neural reflex etiology. A dual chamber Medtronic pacemaker was implanted in the past and subsequent episodes of syncope failed to reveal evidence of malignant ventricular arrhythmia. Although many investigators have demonstrated that real time mobile cardiac telemetry in patients with syncope is superior to alternatives, such patients did not have cardiac implantable electronic devices (CIED) such as pacemakers. (References 1,2) Current Heart Rhythm Society (HRS) expert consensus recommendations for ambulatory electrocardiogram monitoring note that ambulatory electrocardiography is indicated for use in patients with CIED without the need for real time telemetry. (Reference 3) In conclusion, real time mobile cardiac telemetry is not medically necessary. Ambulatory electrocardiographic long-term monitor without real time recording should be utilized. 

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

The insurer's denial of coverage wearable mobile cardiovascular telemetry with electrocardiographic recording is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain

Treatment: Inpatient hospital admission 

The insurer denied coverage for an inpatient hospital admission. 
 
The denial is overturned.

The patient is a female who was currently at 24.3 weeks gestation when she was transferred from Interfaith Hospital reporting lower abdominal pain and back pain. The patient reports positive fetal movement. The patient denied vaginal bleeding, leakage of fluid, headache, urinary symptoms, blurry vision, RUQ (right upper quadrant) pain, or symptoms/exposure to COVID 19 (Coronavirus 2019). The pelvic examination showed a cervix 1-2 cm (centimeters) dilated, Long/Posterior.

A urinalysis was suggestive of a urinary tract infection. Positive Trichomonas was noted. She was admitted for the following: Ancef 2 gm (grams), Betamethasone, intravenous (IV) Hydration, continuous monitoring, Magnesium level q (every) 6 hours, MFM (Maternal-fetal medicine), and NICU (neonatal intensive care unit) consults. A repeat examination later that day showed cervical dilation as the cervix was 2 cm, 40% (percent) effaced, and -3 station. The patient left AMA (against medical advice). During this admission, there was documentation of cervical changes. A repeat cervical examination did show cervical dilation and effacement. So, the patient was in preterm labor.

According to MCG (Milliman Care Guidelines) an admission is indicated for one or more of the following: 1) A condition requiring premature delivery 2) Fetal distress or demise 3) Preterm pre-labor rupture of membranes 4) Significant maternal disease 5) Vaginal bleeding 6) Complications of tocolytic treatment 7) Continued fetal monitoring that requires inpatient care 8) Tocolytic therapy needed that requires inpatient care 9) Inability to stop preterm labor.

Based on the above, admission to the hospital was medically necessary. Tocolytic treatment requiring admission was needed with adequate medical supervision. This is in accordance with standard of care and Milliman Care guidelines.

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The inpatient hospital admission was medically necessary for this patient. 

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied Intracept procedure. 
The denial is upheld.

The patient is a male with back pain. A magnetic resonance imaging (MRI) of the lumbar spine showed multilevel degenerative disc disease with spinal canal stenosis and neural foraminal narrowing. The patient has complaints of low back pain. He is being managed for chronic axial low back pain. The pain radiates upwards. There is no numbness, tingling, weakness. The pain is relatively tolerable. Pain is increased when he bends forward 10-15 degrees. MRI of the lumbar spine was reviewed. Medications include Vicodin, gabapentin and cyclobenzaprine. There has been prior injections performed. Pain score is rated 7 out of 10. Physical exam lumbar spine range of motion restricted, facet leg raise is negative, lumbar facet tenderness with lumbar facet loading maneuvers. The patient's diagnoses include vertebra genic low back pain. There is a plan for Intracept procedure.

The proposed Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain.
There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed Intracept procedure is not likely to be more beneficial than any standard treatment for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied Intracept procedure. 
The denial is overturned.

This is a male who has a one-year history of axial low back pain. He denied any radiating pain, weakness, or tingling/numbing sensation in the lower extremities. Pain is increased with forward bending. He is on Vicodin with some pain relief. His previous treatments included physical therapy (PT), chiropractic care, acupuncture and massage therapy. Pain is rated 5/10 to 7/10. Physical examination is unremarkable except tenderness to palpation (TTP) in the lumbar paraspinal region with positive facet loading. Magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease (DDD) with facet arthropathy and type 2 Modic changes according to the radiology report and provider's note. This patient was recommended to have Intracept procedure.
The issue is whether the Intracept procedure is likely to be more beneficial for this patient's chronic axial back pain based on the available clinical findings and current studies.

The proposed Intracept treatment is likely to be more beneficial than any standard treatment or treatments for the insured's medical condition.
The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient has persistent back pain consistent with degenerative endplate changes. The provider documented Modic type 2 change at lumbar (L)5/sacral (S)1 endplate. Despite his extensive treatments including PT, chiropractic care, acupuncture and massage therapy, his back pain is severe at 7/10. Further interventions are medically necessary to improve his pain. Other potential treatment options are long-term use of medications (NSAIDs, opioids) and lumbar decompression surgery. However, none of these options has a high success rate for chronic axial back pain, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is the appropriate next step intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied Intracept procedure. 
The denial is upheld.

The patient is a male with a history of low back pain. Magnetic resonance imaging (MRI) of the lumbar spine revealed multilevel disc bulging with stenosis. The patient was seen by the pain management physician. It was noted that he was treated with Vicodin, muscle relaxers, anti-inflammatory drugs, trigger point injections, epidural injections and therapy. On exam there was lumbar spasm, facet tenderness and positive Patrick's and Faber tests. The patient was given refills of pain medication and a recommendation was made for Intracept procedure.
The subject under review is whether the Intracept procedure is likely to be more beneficial than any standard treatment for this patient's condition.

The proposed Intracept procedure would not likely be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The limitation of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal injury
Treatment: Consumer Directed Personal Assistance 5 hours per day, 7 days per week (Monday-Sunday) a total of 35 hours per week 
The insurer denied Consumer Directed Personal Assistance 5 hours per day, 7 days per week (Monday-Sunday) a total of 35 hours per week .
The denial is overturned.

This is a case review for a female with medical history notable for car accident resulting in spinal injury, osteoarthritis, and history of cerebrovascular accident (CVA). The patient requested an increase in consumer directed personal assistance services (CDPAS) to 5 hours per day, 7 days per week (total 35 hours per week) which was an increase in 1 hour per day (she currently receives 28 hours per week). This request was denied by the health plan and this denial is the subject under review.

The health plan's determination is overturned.

The requested health service/treatment of Consumer Directed Personal Assistance 5 hours per day, 7 days per week (Monday-Sunday) a total of 35 hours per week is medically necessary for this patient.
The patient has well documented personal care needs as described above and in the Uniform Assessment System (UAS). The tasking tool can be helpful to determine an appropriate amount of help required per week. However, this is best used as a guideline. In a perfect world, all of these activities could be performed sequentially in the minimum time necessary. In reality, these tasks may not occur as seamlessly or easily as described. Further, the current allotment of hours is actually less than the task tool recommends. An increase in 1 hour per day would allow for the actual number of hours required per the task tool with a small buffer. Furthermore, the physician documented personal care needs that are not being met under the current level of CDPAS. This further demonstrates the medical necessity of additional hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Injection of sclerosant
The insurer denied the injection of sclerosant.
The denial is overturned.

The patient, an adult female, presented with left leg varicose veins with symptoms of pain and swelling. The patient has worn compression stockings regularly with no relief. Her symptoms were severe enough to interfere with normal function. Duplex testing showed severe reflux, greater than two seconds, and enlargement, greater than six milliliters, of the left short saphenous vein (SSV). The provider has recommended Varithena closure of this vein. Coverage was denied on the basis that the documentation does not demonstrate indications for the procedure such as bleeding or ruptured superficial veins, recurrent varicosities after prior vein stripping or ablation, or symptomatic superficial varices (localized).

The proposed treatment is medically necessary.

Under widely accepted criteria [1-5], endovenous closure of an axial saphenous vein is medically necessary when:
1) The patient has venous insufficiency symptoms severe enough to affect normal function. 2) The patient has failed a trial of prescription compression stockings. 3) The patient has duplex-proven reflux affecting the vein in question and the reflux can be reasonably construed as a cause of the patient's symptoms.

Requirement # (number) 1 has been met. The office note documents painful varicosities, leg pain, and swelling. The symptoms were documented to be severe enough to affect normal function. The provider reiterated the patient's symptoms in an appeal letter.

Requirement #2 has been met. As stated above, the patient failed compression stockings, which have given her no relief.

Requirement #3 has been met. The patient had a venous reflux study demonstrating enlargement and severe small saphenous vein (SSV) reflux on the same side as her symptoms.

Therefore, the patient meets published, well-accepted criteria for left small saphenous vein (SSV) closure. Varithena injection is an appropriate method of achieving small saphenous vein closure.

The denial letter stated that the documentation does not demonstrate indications for sclerotherapy. However, the criteria applied were those used for sclerotherapy of branch varicose veins, not the criteria used for axial vein closure. Varithena can be used for either procedure. In this case, the provider is using Varithena for axial vein closure. The prior denial applied the incorrect criteria.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Neck Pain
Treatment: Formulary exception for Oxycontin (oxycodone ER) [extended release]
The insurer denied: Formulary exception for Oxycontin (oxycodone ER)
The denial is overturned

The patient is an adult male with chronic neck pain. He has been prescribed Oxycontin extended release 40 mg (milligrams). The patient has been on this medication since several years ago. He is followed by a pain management physician. The patient's physical exam is non-focal.

The health plan should cover the Formulary exception for Oxycontin.
The patient is an adult male with chronic neck pain who has been prescribed Oxycontin extended release 40 mg (milligrams).

The patients been on this medication for nearly 10 years. He is followed by a pain management physician. This is a continuation of therapy. The patient is evidenced to be followed regularly by his pain management team. He has previously tried a long acting medication, specifically methadone. No red flags are evidenced. Given that the patient is stable on this medication for nine years, the risk of opiate rotation outweighs the benefits. Risks of changing the patient's medication despite being stable can result in increased pain and diminished function. There is no literature data to support that formula alternatives will be superior to the current medication.

Therefore, given the above, the health plan should cover the formulary exception for Oxycontin.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and Foot Pain. 
Treatment: Inpatient Hospital Admission. 
The insurer denied the Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female who was admitted to the hospital for low back and foot pain. She presented to the emergency department in severe pain, sobbing. She was unable to participate in the physical exam, but was reportedly moving all four extremities without difficulty. She was admitted due to lack of caregiver support at home. She has a history of chronic generalized body pain but developed three days of severe pain. She was worked up for deep vein thrombosis as well as epidural hematoma and was subsequently discharged. 

The proposed inpatient hospital admission was not medically necessary. 

If there is concern of deep vein thrombosis, Venus Doppler's can be ordered in the emergency department. In addition, with regards to concern over myelopathy/epidural hematoma, stat magnetic resonance image (MRI) can be ordered in the emergency department. This was not done. No magnetic resonance image (MRI) was ordered. Computed tomography (CT) scans were negative and showed only degenerative changes, no acute findings. Given the lack of diagnostic criteria to support either of these diagnoses, and the fact that these diagnoses can be worked up in the emergency department, the subsequent admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with prior history of appendicitis that was managed nonoperatively. The patient never followed up and returned to the emergency department for persistent abdominal pain for one week. 

On admission, the patient was guarding and had a positive McBurney sign. Her white blood cell (WBC) count was 12. Her potential of hydrogen (pH) was 7.29, and lactic acid was elevated. The computed tomography (CT) showed persistent appendicitis with smaller abscess. The patient was started on intravenous fluids / antibiotics. Her white blood cell count improved and the patient was discharged the next day doing well.

Yes, the proposed inpatient hospital admission was medically necessary.
The patient was admitted with a diagnosis of acute appendicitis with residual or new abscess. The patient had a prior episode of appendicitis that she was treated for non operatively. The patient had an elevated white blood cell count and high lactic acid. She did not have any derangements in her vitals. The surgical team acted appropriately to admit her to watch her white blood cell count and follow her abdominal exam. She was discharged after her white blood cell count normalized and her exam was stable. 

Overall, with the finding of the small abscess, this is not from her prior episode rather a new abscess that was treated non operatively. Appendiceal abscess that are small can be treated non operatively without percutaneous or operative drainage, however, given her leukocytosis and elevated lactate, it is prudent to admit and watch to ensure there is improvement or stabilization of symptoms.

Inpatient stay is necessary as the  patient likely had a small abscess from a microperforation of the appendix. Leukocytosis and elevated lactic acid demonstrated a Systemic Inflammatory Response Syndrome (SIRS)/sepsis response and necessitated inpatient level of care.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flu-like symptoms
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This male patient with a history of polysubstance abuse presented from inpatient rehab with approximately four days of progressive flu-like symptoms.  He had history of COVID infection five weeks ago. 

The patient's vital signs revealed the following: temperature = 37.2, pulse = 82, respiratory rate = 16, blood Pressure = 179/96, and oxygenation saturation = 96%.  His exam was remarkable for pharyngeal edema.  The patient's labs revealed the following: white blood cells (WBC) = 14.69, hemoglobin/hematocrit (H/H) = 13.5/41.2, platelet (Plt) = 267, sodium (Na) = 137, potassium (K) = 4.2 and blood urea nitrogen/creatinine (BUN/Cr) = 13/1. The patient's COVID and influenza were negative; beta hemolytic strep was positive.  The patient had a normal electrocardiogram.  His chest x-ray showed no acute disease. His Clinical Institute Withdrawal Assessment for Alcohol ( CIWA) was zero. 

The patient was admitted with sepsis.  Plan of care included intravenous antibiotics.  The patient's vital signs were stable and he was afebrile. Plan to change was to oral antibiotics.  An attempt was made to transfer back to inpatient rehab.  The patient was discharged.

No, the proposed treatment was not medically necessary.
This patient was admitted after presenting with flu-like symptoms and being diagnosed with strep pharyngitis. The patient was hemodynamically stable and afebrile.  He did not have bacteremia.  He did not have end organ dysfunction.  He was cleared for treatment with oral antibiotics.  He did not require inpatient admission for intravenous antibiotics.  Hospital stay was prolonged pending transfer back to inpatient rehabilitation.  He did not require treatment at an acute inpatient level of care.  The inpatient hospital admission was not medically necessary.

Yes. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

This is a female with a painful left knee. She had a previous history of several spine surgeries, diabetes and hypertension. She was classified as American Society of Anesthesiologists classification III (ASA3). She underwent a left total replacement. She had chronic opioid use and deformity to her knee. Her surgery was completed and she was discharged on day five. 

The records show comorbidities and problems encountered after the surgery. This patient has a history of chronic opioid use. Her medication requirements for pain were significantly higher than most post surgical patients. The records show a catheter for pain medication was required until at least post-operative day (POD) #3. There was documentation to her being tearful, pain seeking behaviors and requirement of a Ketamine infusion. She received multiple intravenous doses of narcotics. She required constant Pain Management consultations. 

These services (Pain Management, long term catheter and Ketamine infusion) could not be provided at a lower level of care. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.