Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Angle-Closure Glaucoma, Bilateral Severe Stage
Treatment: Cosopt, Pre-service
The insurer denied the Cosopt, Pre-service
The denial is overturned

The patient is a male with chronic angle-closure glaucoma, bilateral severe stage, for whom continued coverage of Cosopt (dorzolamide/timolol) PF is the subject of review. Coverage was previously denied per policy as it was not identified that the patient had tried and had an inadequate treatment response or intolerance to the required number of formulary alternatives or that the patient had a documented clinical reason such as an expected adverse reaction or contraindication that prevents him from trying the formulary alternatives. Formulary alternatives include dorzolamide-timolol, latanoprost, and travoprost (generic Travatan Z). Clinical records show this patient with severe optic nerve cupping being treated with the requested medication for a few years. 

Upon appeal, it is identified that the patient has tried dorzolamide-timolol, Combigan (brimonidine-timolol), latanoprost, Lumigan (bimatoprost), Travatan Z (travoprost), Alphagan P (brimonidine), brimonidine, Vyzulta (aatanoprostene bunod), Rhopressa (netarsudil) and Rocklatan (netarsudil-latanoprost) in the past with adverse reactions as well as inadequate control of intraocular pressure. The patient is noted to have a benzalkonium chloride (BAK) allergy as well.

Yes, the health plan should cover the proposed Cosopt PF.
Formulary alternatives include dorzolamide-timolol, latanoprost, travoprost (generic Travatan Z).  Upon appeal, it is identified that the patient has tried dorzolamide-timolol, Combigan (brimonidine-timolol), latanoprost, Lumigan (bimatoprost), Travatan Z (travoprost), Alphagan P (brimonidine), brimonidine, Vyzulta (latanoprostene bunod), Rhopressa (netarsudil) and Rocklatan (netarsudil-latanoprost) in the past with adverse reactions or inadequate control of intraocular pressure. The patient is noted to have a benzalkonium chloride (BAK) allergy as well. 

The patient has tried all of the formulary alternatives above, either alone or in combination. So, it is established that all of the formulary drugs have either been ineffective for the patient or have produced adverse effects for this patient. The patient has demonstrated control of intraocular pressures and tolerance to the requested medication. Therefore, continued coverage of Cosopt PF should be covered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive Emergency

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

The patient is an adult male that presented to the hospital with poorly controlled hypertension. His blood pressure was noted to be 201/133. An electrocardiogram (ECG) revealed normal sinus rhythm with left ventricular hypertrophy (LVH) and lateral ST-T (interval on ECG) wave abnormalities. Serum blood testing revealed a mild elevation in troponin of 0.075 nanogram (ng)/milliliter (ml). Following treatment, the patient's blood pressure dropped to 182/99 and the patient was admitted and further treated with intravenous (IV) nicardipine. His blood pressure normalized and he was discharged the following day.

Hypertensive emergency is defined as blood pressure greater than (>) 180/120 with target organ damage (1). The American Heart Association guidelines recommend admission to the intensive care unit (ICU) for management of hypertensive emergencies (1). Treatment goals for hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequences of rapid blood pressure correction (2).

In this patient, the patient's troponin was elevated, consistent with target organ damage. The patient responded to IV antihypertensive medications (nicardipine and hydralazine). This patient should have been managed at a higher level of care. Inpatient admission to manage the patient's hypertensive emergency was medically necessary.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute perforated appendicitis.

Treatment: full hospital admission.

The insurer is denied coverage for full hospital admission.

The denial is overturned. 

This male patient has a history of childhood asthma and anxiety.

Per Milliman Care Guideline (MCG) Health Appendectomy, with Abscess or Peritonitis, by Laparoscopy RRG, goal length of stay is ambulatory or two days postoperatively. MCG criteria also indicate that discharge readiness is indicated by patient meeting all recovery milestones, including pain absent or managed, and oral medications or regiment acceptable for next level of care. Per clinical documentation, this patient developed worsening abdominal pain. In the setting of an appendiceal perforation, continued intravenous antibiotics were needed. Admission may also be necessary for patients with severe systemic illness (eg, sepsis), poorly controlled comorbidities (eg, chronic obstructive pulmonary disease [COPD], chronic heart failure), or complications from the procedure (eg, infection, bleeding) that require more than 24 hours of postoperative care. Per provided clinical documentation, inpatient admission was medically necessary.

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

The carrier's denial of coverage for the full hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic low back pain.

Treatment: lumbar interlaminar pain injections.

The insurer is denied coverage for lumbar interlaminar pain injections.

The denial is overturned. 

This female patient has a history of chronic low back pain

Manchikanti et al. (1) published new clinical practice guidelines that support the use of another epidural steroid injection (ESI) in this patient. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) (4) supports up to 6 ESIs per year. 

Lee et al (2) reviewed the literature and found that: "Unfortunately, there is no definite consensus on what constitutes the appropriate regimen of ESIs, and little information concerning recommendations or practice guidelines is available to date.
 
Before discussing appropriate ESI interval, physicians should consider the need to repeat ESI multiple times. Repeated ESIs within 3 months provide cumulative benefit. If multiple ESIs are considered, an appropriate interval between ESIs should be decided based on the average duration of hypothalamic-pituitary-adrenal (HPA) axis suppression after ESI without affecting the physiological restoration. Another rationale for an appropriate interval is to wait until the peak effects of epidural steroid treatment are detected to avoid needless additional ESI.

The World Institute of Pain (WIP) Benelux working group recommended that the number of ESIs should be adjusted according to the clinical response, suggesting that a 2-week interval for additional ESI may be appropriate for proper evaluation and minimization of endocrine side effects, and the lowest effective dose should be used for ESI (40 mg(milligram) for methylprednisolone, 10 to 20 mg for triamcinolone acetate, and 10 mg for dexamethasone phosphate)."

Similarly, Van Boxem et al (3) conducted a multi-society review and concluded: "There is no ideal number of injections; the number of treatments should be individually adjusted in accordance with clinical response. However, consensus has been reached that additional treatments, may only be administered after a 2-week interval in order to allow proper evaluation and minimize endocrine side effects."

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

The carrier's denial of coverage for the lumbar interlaminar pain injections is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Fibroids

Treatment transcervical uterine fibroid ablation with ultrasound guidance procedure, code 0404T

The insurer denied coverage for transcervical uterine fibroid ablation with ultrasound guidance procedure, code 0404T

The denial is overturned

The patient has a history of uterine myomas, endometrial polyp, heavy menses, and dysmenorrhea. An ultrasound of the pelvis demonstrated an enlarged myomatous uterus. Ultrasound showed 8 fibroids less than 4 centimeters (cm) in size.  Coverage is requested for transcervical uterine fibroid ablation with ultrasound guidance procedure, code 0404T for treatment of fibroid tumors.

The Sonata System combines intrauterine ultrasound (IUUS) with radiofrequency (RF) ablation in a single handpiece. Sonata is suitable in an inpatient or outpatient setting and is intended for diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding.
The Sonata system is Food and Drug Administration (FDA) approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids. Symptomatic improvement is observed within the first three months post procedure, and this improvement has been maintained at least through 24 to 36 months of follow-up. Women treated with the Sonata pivotal trial experienced significant and durable reduction of fibroid-related symptoms, with low surgical reintervention rates over years of follow-up.

In summary, the requested procedure is medically necessary. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The coverage for transcervical uterine fibroid ablation with ultrasound guidance procedure, code 0404T for treatment of fibroid tumors is considered medically necessary for this patient.

The insurer's denial of coverage for transcervical uterine fibroid ablation with ultrasound guidance procedure, code 0404T for treatment of fibroid tumors is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alpha-1 antitrypsin (AAT) deficiency

Treatment Prolastin-C (alpha 1-proteinase inhibitor [human])

The insurer denied coverage for Prolastin-C (alpha 1-proteinase inhibitor [human])

The denial is upheld

The patient has a history of Alpha-antitrypsin (AAT) deficiency questionable chronic obstructive pulmonary disorder (COPD), obstructive sleep apnea (OSA). The patient has (Alpha-antitrypsin deficiency) Pi ZZ (severe form of AAT) phenotype and  AAT level was <25mg/dL (milligram (mg)/deciliter (dL).  As per physician's visit, the patient as had COPD for years and was on beta 2 agonists as needed. The patient had been treated with Advair for past few years.  The patient was afebrile and hemodynamically stable. Oxygen (O2) saturations 92 % (percent) on room air. The patient was 240 pounds.  The patient had been on continuous positive airway pressure (CPAP) with 3 liters nasal cannula at night for OSA. There was some shortness of breath (SOB) on exertion. The lungs were clear. The computed tomography (CT) chest revealed no evidence of lung pathology. There was no emphysema.  The pulmonary function tests (PFT) were read as no obstruction; lung volumes and diffusing capacity are normal.  This patient did not have any evidence of emphysema by PFT or clinical exam or on CT chest.  This patient did not meet replacement guidelines for AAT replacement which are: forced expiratory volume (FEV1) between 30-65 % predicted. This patient had FEV1 of 85 % predicted.
There was no documentation of decline in FEV1 by >100. There was no obstruction on Spirometry. This patient had only 1 PFT which was normal.  The patient was morbidly obese and that may have been contributing her symptoms of SOB.

This patient did not need AAT replacement based on nationally recognized guidelines. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Prolastin-C (alpha 1-proteinase inhibitor [human]) for the treatment of alpha-1 antitrypsin deficiency is not substantiated. The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Saccadic Eye Movement and Paresis of Accommodation

Treatment: current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation

The insurer denied coverage for current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation

The denial is upheld

This case involves a child who has been previously diagnosed with cerebral palsy as well as dysgraphia and dyspraxia.  The documentation indicated the patient has been previously recommended for the requested services.  The patient started patient therapy services. The documentation indicated he did undergo initial testing indicating his full-scale IQ (intelligence quotient) was on the low end of average.  The documentation indicated he was seen for an evaluation.  The patient had 20/20 acuity when measured at the normal testing distance of 20 feet.  There was the ability to maintain focusing as well as shift focus from far to near without eyestrain.  The documentation indicated the patient does have significant difficulty changing focus from one distance to another which may cause symptoms such as holding a book to close with difficulty with copying from a board and may contribute to headaches or eyestrain.  Furthermore, the documentation indicated the patient scored significantly below age level with tracking and concentration as well as visual motor integration and speed.  The submitted documentation indicated the patient was recommended to participate in 9 months of neurodevelopmental therapy due to the above.

For the diagnoses listed, there is not an abundant amount of literature supporting improvement.

While this treatment has final approval, it is typically prescribed for other diagnoses.

The patient is not a good candidate. It is not the best available treatment. There are no adverse risks increased. This treatment is not likely to be more beneficial than any other standard treatment.

The carrier's denial of current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation; should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Saccadic Eye Movement and Paresis of Accommodation

Treatment: current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation

The insurer denied coverage for current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation

The denial is upheld

Visual acuities were 20/20 in both eyes.  The note stated that patient had difficulty with accommodation and scored below age level for fixation-processing speed, tracking/concentration, letter reversals, and visual-motor integration and speed, and visual memory. The doctor noted diagnoses of saccadic eye movement and paresis of accommodation and recommended nine months of neuro-developmental therapy.

Another note indicated that patient has cerebral palsy, dystrophia and dyspraxia and recommended vision therapy to help with tracking and visual processing.

It was noted that eye movement speed and accuracy, accommodation, fusional skills, visual performance fields have improved.  Diagnoses of oculomotor dysfunction, accommodative insufficiency and visual field defect were noted.  The was patient noted to be making good progress with vision therapy.

There is insufficient evidence in the peer-review literature to support the effectiveness of vision therapy, and lack of consensus about the use of such therapy for the patient's conditions. (Helveston 2005, Horwood 2014).

Indeterminate.  There is insufficient evidence in the literature to support the use of CPT 92065 for dyslexia and other reading/learning disabilities.

CPT 92065 is not the best available treatment for this patient at this time.  There are no other alternatives for vision treatment other than observation. The adverse risks are not increased over standard treatment/services (observation).  Vision therapy does not have increased adverse risk compared to observation.

CPT 92065 is not more beneficial than any of the standard treatments/procedures for this patient. CPT 92065 is considered its clinical value for the patient's condition has not been established based on peer-reviewed literature.

The literature on the effectiveness of vision therapy for ocular motor disorders has largely been characterized by anecdotes, case reports, or uncontrolled studies with small sample sizes.  These case series are unable to determine whether bias has occurred due to maturational effects, test-retest effects, and the non-specific gains accrued simply by bestowing more attention on a child (Levine, 1984). 

The American Academy of Ophthalmologists (AAO), the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Pediatrics (AAP) concluded that vision therapy is not an effective treatment for reading problems and other learning disabilities.

The carrier's denial of current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation; should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right-Hand abscess

Treatment: inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is overturned.

The patient has a past medical history significant for hand injury following a recent assault who returned to the emergency department with complaints of right hand pain, swelling, and erythema, as well left elbow bursitis.  Vitals on presentation included: Temperature 97.7, blood pressure (BP) 135/80, pulse 75, respiratory rate (RR) 12, oxygen saturation was 100% (percent) on room air. Laboratory results included the following; white blood count (WBC) 19.24, hemoglobin (Hgb) 12.4, hematocrit (Hct) 38.4, glucose 91, creatinine 0.93. 

The patient was started empirically on intravenous antibiotics (vancomycin and Unasyn). X-ray showed fracture of the dorsal base of the 5th digit middle phalanx. Hand service performed an incision & drainage, and right middle MCP (metacarpophalangeal) arthrotomy procedure. Wound cultures grew Streptococcus pyogenes and methicillin-resistant Staphylococcus aureus (MRSA). He underwent wound care. The patient remained afebrile, hemodynamically and clinically stable. He was discharged to continue treatment (Bactrim) as an outpatient.       

According to documentation, patient was re-admitted for a worsening right-hand abscess and drainage following an assault and bite injury the week before. He was afebrile, stable hemodynamically; however, laboratory values were notable for an elevated WBC (19.24). Clinically, his injured hand showed worsening drainage despite outpatient management, requiring surgical intervention. Based on these findings, patient required hospital admission for intravenous antibiotics and surgical intervention for management of high-risk hand injury that failed outpatient management. 

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

Based on the above, the medical necessity for the inpatient level of care is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Confusion and disorientation. 
Treatment: Inpatient admission. 

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

The patient is a female who presented to the emergency ward after an episode of transient confusion. At presentation, she was at her baseline cognitive status and she had a normal neurological examination. National Institutes of Health (NIH) stroke scale score was zero. Computed tomography (CT) of the brain, computed tomography (CT) angiogram and computed tomography (CT) perfusion studies were all normal. 

No, the proposed inpatient admission was not medically necessary. 

The patient had an episode of transient confusion completely resolved by the time of presentation, with a normal neurological examination as well as negative neuro-imaging at presentation, including computed tomography (CT) perfusion study. The clinical assessments, monitoring, diagnostic studies and treatments could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diplopia. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This case involves a patient who presented to the emergency department complaining of double vision.  The documentation does indicate she underwent a COVID (2019 Novel Coronavirus) vaccine and the following day developed double vision.  There was no numbness or tingling of the arms or legs and no complaints of headache, nausea, vomiting or fever.  The documentation does detail she has a history of hypertension as well as diabetes.  Upon physical examination she had a temperature of 99.6 with a heart rate of 117.  Oxygen saturation was 98% (percent) on room air and her blood pressure was 135/86.  The physical exam revealed she was alert and oriented.  She was unable to fully abduct her left eye.  The physician indicated she possibly had a VI (6th) nerve palsy on the left.  It was recommended she undergo laboratory diagnostic studies.  She underwent a chest x-ray revealing clear radiodensities.  Her laboratory studies did reveal a glucose of 332.  A computed tomography (CT) scan revealed no acute intracranial pathology and the physician indicated she was recommended to be admitted for further treatment.  The documentation detailed she was given aspirin as well as verapamil.  She underwent a consultation by neurology where there were no inpatient services recommended.  The documentation detailed she continued to improve and did not have any further adverse events.  She was also treated with insulin as well as glipizide and Metformin.  She was discharged the following day with instruction to follow-up. 

The patient presented to the emergency department (ED) with double vision in the aftermath of a COVID-19 vaccinations. On examination patient was unable to fully adduct her left eye. The patient was evaluated in the ED and admitted to the hospital. CT imaging study of the head showed no hemorrhage or acute intracranial process. The patient was evaluated by neurology and was treated with aspirin therapy coupled with Verapamil. Symptoms improved and patient was discharged with outpatient follow up set up. Care provided, including imaging study, medical management and specialty consultation did not warrant inpatient admission. Care provided could have been performed in the ED setting and at an outpatient level of care. 

Therefore, the inpatient admission was not warranted or medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital is upheld. Medical Necessity is not substantiated.