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

Diagnosis: Chest pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She has a past medical history significant for HTN (hypertension), GERD (gastroesophageal reflux disease), back pain, psoriasis, dyslipidemia, CAD (coronary artery disease), status post PCI (percutaneous coronary intervention) of LAD (left anterior descending artery). She presented to the ER (emergency room) with complaints of new onset chest pain, pressure like, radiating to the left arm, associated with dyspnea, relieved by nitroglycerin.

The patient was admitted for suspected unstable angina. The patient was hemodynamically stable. ECG (electrocardiogram) revealed no acute ischemic changes. The patient was referred for cardiac catheterization, and was found to have non-obstructive CAD (coronary artery disease), which was managed medically. Echocardiogram was performed and revealed normal LV (left ventricle) systolic function. She was discharged home with a plan for outpatient follow-up.

Yes, the Inpatient admission was medically necessary.

The patient presented with new onset chest pain, with features suggestive of unstable angina. The patient had multiple risk factors for CAD (coronary artery disease), as well as a known history of coronary artery disease, including a history of prior percutaneous revascularization with stent placement. There was a high index of suspicion for an ACS (acute coronary syndrome), and a cardiac catheterization was performed. Given the presentation, risk factors, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an ED (emergency department) chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the Inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent 300MG/2ML Syringe Weekly dosing. 

The insurer denied the Dupixent 300MG/2ML Syringe Weekly dosing. 
The denial is upheld. 

The patient is a female with severe atopic dermatitis, treated with topicals, cyclosporine and Dupixent (every other week) injections. The patient has improved on Dupixent, but still has 20% BSA (body surface area) involvement. Her provider is requesting increasing Dupixent to weekly injections. 

No, the weekly Dupixent is not medically necessary. 

Medically necessary is generally defined as treatment that is in accordance with generally accepted standards of good medical practice; clinically appropriate and considered effective; not primarily for the convenience of the patient or provider; and at least as likely to produce an equivalent therapeutic outcome as alternative services. 

There is no current literature support for use of Dupixent weekly. The article (Worm et al) studied weekly and every other week regimens, and concluded that the approved regimen (every two weeks) maintained clinical response and is therefore recommended for long-term treatment. No other articles were found to support weekly dosing. Therefore, weekly dosing cannot be considered within good standards of medical practice at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Taltz (Pre-service).

The insurer denied the Taltz (Pre-service).  The denial is upheld.

The patient is a male with psoriasis affecting greater than (>) ten percent body surface area (BSA) for whom Taltz injections are requested. He has tried and failed Stelara, Tremfya, Protopic, topical steroids and phototherapy.

No, the proposed treatment is not medically necessary.

The plan offers formulary medications that are on par with the efficacy and safety of Taltz for moderate to severe psoriasis, such as Cosentyx.  There is no documentation of side effects, intolerance, or contraindication to the use of the available formulary medication, which is approved for use in this indication and has the same mechanism of action as Taltz (IL [Interleukin] 17 inhibitor).

There is no documentation that the patient is intolerant or has a contraindication to the use of Cosentyx, which also acts via IL17 (IL [Interleukin] 17 inhibitor) inhibition and is a formulary medication.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease
Treatment: Zephyr Valve Procedure
The insurer denied the Zephyr Valve Procedure.
The determination is overturned.

The patient has known severe chronic obstructive pulmonary disease (COPD) with forced expiratory volume in on second (FEV1) of 21% predicted, DLCO 57% predicted, previous smoker who quit; is on no supplemental oxygen with multiple maximal COPD medications and optimized medical management and continues to be dyspneic and unable to carry out daily functions and activities. He had a six minute walk distance of 214 meters with no hypoxemia. An arterial blood gas (ABG) showed no hypercapnia. He had an unremarkable echocardiogram with no pulmonary hypertension and normal body mass index (BMI). He has not undertaken a pulmonary rehabilitation program based on the available reports.
The patient has been evaluated for bronchoscopic lung volume reduction surgery with endobronchial valves. He has undergone an extensive work up for the assessment and evaluation of this procedure including a computed tomography (CT) scan of the chest with Stratx reporting, differential lung scan, cardiac single-photon emission computed tomography (SPECT) scan and echocardiogram.
At issue is whether the Zephyr Valve Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Based on a review of medical records, the proposed health service or treatment Zephyr Valve Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is already under maximal treatment for his disease with multiple inhalers and nebulizers. As stated in the accompanying literature from both the appealing physician and insurance provider, multiple recent studies including randomized control trial from 2015 -2019 have shown significant clinical benefit in symptomatic dyspnea after placement of a Zephyr valve in carefully selected individuals. This patient has gone through all of the required pre-procedure testing deemed necessary and he meets all the needed inclusion criteria without any exclusions or contraindications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Pap Smear.
Treatment: Loop electrosurgical excision procedure (LEEP).

The insurer denied coverage for loop electrosurgical excision procedure (LEEP).  The denial is upheld.

The patient is a female with a history of an abnormal pap smear and generalized anxiety disorder (GAD).  She presented to the Obstetrician/Gynecologists (OBGYN) office for a consultation for a loop electrosurgical excision procedure (LEEP) for a recent abnormal pap smear. The physician requested that the procedure be done in a hospital setting due to a history of GAD.

The insurer has denied coverage for the CPT code 57522, conization of cervix in a hospital setting, as not medically necessary. 

LEEP procedures are usually performed in the office under local anesthesia or in an ambulatory surgical setting under monitored anesthesia care or under general anesthesia.

It is unclear why the provider would like to perform a LEEP procedure in the hospital. According to the provider, the patient has GAD and needs extra time waking up from anesthesia. There is no medical information in the scientific literature that people with GAD need extra time to wake up from anesthesia.

The procedure can be easily performed in an ambulatory surgical setting and the patient can take all the time needed to wake up from anesthesia. The anesthesia is the same in a hospital or in an ambulatory surgical setting. The patient will wake up when she wakes up. It is unclear how a hospital will make any difference in waking up.

The patient does not have any medical condition that needs hospital admission and stabilization before or after the surgery. 

In summary, there is no scientific or clinical reason for this procedure to be done in a hospital.

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

The Current Procedural Terminology (CPT) code 57522, conization of cervix in a hospital setting is not considered medically necessary for this patient.

The insurer's denial of coverage for the CPT code 57522, conization of cervix in a hospital setting is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, coronary artery disease, hypertension, severe osteoarthritis, urinary incontinence, dementia, depression and renal insufficiency

Treatment: Home Care/Personal Care Home Health Care (HHC)-Level II Personal Care Services, Per 15 Minutes Increase To 24 Hours(2) Per Day (split shift)

The insurer denied the Home Care/Personal Care HHC-Level II Personal Care Services, Per 15 Minutes Increase To 24 Hours(2) Per Day (split shift).

The denial is overturned. 

The patient is a male with a history of congestive heart failure, coronary artery disease, hypertension, severe osteoarthritis, urinary incontinence, dementia, depression and renal insufficiency. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). 

Appeal review requested for potential approval of home care/personal care HHC-level II personal care services, per 15 minutes increase to 24 hours(2) per day (split shift).

Yes, the proposed treatment of home care/personal care HHC-level II personal care services, per 15 minutes increase to 24 hours(2) per day (split shift), is deemed medically necessary.

This is a male with a history of  congestive heart failure, coronary artery disease, hypertension, severe osteoarthritis, urinary incontinence, dementia, depression and renal insufficiency.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).  

Although an assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of home care/personal care (HC/PC) level II - personal care services (PCS) per 15 minutes, one day is sufficient to meet the patient's current needs, the patient's Primary Medical Provider, relates this schedule leaves the patient unattended during overnight hours while his home health aide is asleep. This is problematic as his urinary incontinence and history of pressure ulcers requires constant monitoring/care for toileting, changing bedsheets/linens and wound care. In addition, he needs to be turned in bed every two hours to prevent worsening of his chronic bedsores. 

Hence, provision of home care/personal care HHC-level II personal care services, per 15 minutes increase to 24 hours(2) per day (split shift) can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment of home care/personal care HHC-level II personal care services, per 15 minutes increase to 24 hours(2) per day (split shift) is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Varicose Veins.
Treatment: Vein Treatment (sclerotherapy), Pre-service.
The insurer denied the Vein Treatment (sclerotherapy), Pre-service.
The denial is upheld. 

The patient is a female with history of venous disease and venous insufficiency. The patient underwent bilateral great saphenous vein endovenous ablation, which was successful. The patient has residual refluxing branches involving bilateral calves. The patient has no active ulceration, bleeding, phlebitis or complications associated with the varicosities.

No, the health plan should not cover the sclerotherapy.
The patient is a female with history of venous disease and venous insufficiency.  The patient underwent prior left great saphenous vein endovenous ablation and right great saphenous vein endovenous ablation.  The patient was seen in follow-up visit and noted to have refluxing tributary branches on follow up ultrasound.

Office note states that patient has Spider veins, varicose veins and leg pain, heaviness, swelling.  The patient states the symptoms began several years ago.  Level of pain is 7 out of 10.  The patient has worn compression stockings for over six months. Physical exam shows no evidence of varicosities bilaterally.  There is presence of no telangiectasia on the left side there is telangiectasia noted on the right side.

Venous duplex scan shows ablated bilateral great saphenous vein including left and right great saphenous veins. There is medial calf branch accessory reflux on the right side and on the left side.

The patient's symptoms are out of proportion to physical findings and venous finding.  The patient already had bilateral endovenous ablations with duplex scan showing closure of the both great saphenous veins extending to below the knee, which should have improved patient's symptoms and complaints.  If patient in fact has severe symptoms in both legs, then other etiologies needs to be sought.  The patient has no evidence of any significant varicosities based on physical exam and would explain patient's symptoms.  The patient only has refluxing branch veins involving the calf area bilaterally, which does not explain the patient's significant symptoms.  The patient has no active ulceration, bleeding, phlebitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins

Treatment: Procedure code 36475, endoluminal ablation of varicose veins in the legs

The insurer denied coverage for procedure code 36475, endoluminal ablation of varicose veins in the legs.

The denial is overturned.

This case involves a female patient who was seen regarding varicose veins over the lateral left thigh which traversed laterally to cross the knee. The documentation indicated she complained of her leg being heavy with achiness. She does report a laser procedure on the same vein many years ago which has made it worse over time. She stands most of the day and has had 2 prior episodes of cellulitis to the left foot. She does utilize compression stockings. The physician referenced her prior ultrasound demonstrating an incompetent anterior accessory great saphenous vein (AAGSV) which crosses the knee connecting to large varices in the lateral and posterior calf. There are several perforators without reflux. The physical exam revealed a large varix from the left groin wrapping laterally around the thigh crossing the knee into the calf. The physician indicated she had a large incompetent anterior accessory vein from the left groin which extended and was painful after standing. She has also had several episodes of left ankle cellulitis due to venous hypertension. She was recommended to undergo an AAGSV radiofrequency ablation (RFA) closure with phlebectomy of the upper thigh.

This is a case of a female with history of left lower extremity edema, heaviness, and pain. She also has had previous laser ablation of the main great saphenous (GS) truncal vein and has had venous insufficiency related cellulitis in the past. She regularly utilized compression stockings, per the medical record.

Recent venous reflux study reveals left anterior accessory saphenous vein (AASV) reflux throughout the thigh, with multiple collateral superficial veins in the left thigh and calf regions which all collectively drain into the AASV and thus are involved in the symptomatic reflux. The degree of reflux is severe and over 0.5 sec. Images of the physical exam demonstrate and confirm large superficial collaterals off the AASV trunk extending lateral into calf. 

Though the insurance plan states that the AASV can only be ablated when there is associated saphenous-femoral junction reflux, the correct approach is to ablate an isolated AASV that is incompetent. AASV incompetence plays a significant role in the symptoms of venous reflux, and in fact, the AASV reflux produces more episodes of phlebitis compared to GSV reflux. Note that this patient has had cellulitis and phlebitis episodes in the past. There need not be associated saphenofemoral junction (SFJ) reflux with the AASV in order to proceed with AASV ablation.

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 procedure code 36475, endoluminal ablation of varicose veins in the legs is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Temporomandibular Joint Pain.

Treatment: J0585, Botox (onabotulinum toxin) to treat myofascial pain.

The insurer denied coverage for J0585, Botox (onabotulinum toxin) to treat myofascial pain.

The denial is upheld.

Upon review of submitted documentation which includes treatment records and narrative report of treating providers, it appears that this patient has an underlying diagnosis of TMJ [temporomandibular joint] pain, bruxism, and myofascial pain. This patient has been under the care of her physician who recommended Botox injections as enumerated above to treat the jaw/muscle pain. The insurer has denied this service stating that although there is evidence that botox is helpful for certain conditions there is insufficient evidence to support this treatment as being of value in managing this patient's myofascial pain.  

Upon review of peer reviewed literature (see enumerated representative references below) there is a body of literature to suggest that Botox injections may be safely administered and possibly of some benefit in managing TMJ/ myofascial pain. However, most literature consists of case reports/anecdotal reports of its efficacy. There are no randomized controlled studies that report any benefit, nor any greater benefit than conventional treatments, and therefore Botox cannot be considered a standard treatment. In fact, most literature, including references noted below, report no clear efficacy of Botox in managing bruxism, TMJ or myofascial pain when compared to standard treatments. "A meta-analysis was not possible because of the considerable variation in the studies' designs, the heterogeneity between the groups, and the different assessment tools used. Despite showing benefits, consensus on the therapeutic benefit of BTX [Botox] in the management of myofascial TMD [temporomandibular disorders] is lacking. Further randomised controlled trials with larger sample sizes, minimal bias, and longer follow-up periods are now needed."

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. J0585, Botox (onabotulinum toxin) to treat myofascial pain is not considered medically necessary for this patient's clinical scenario.

The insurer's denial of coverage for J0585, Botox (onabotulinum toxin) to treat myofascial pain is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain.
Treatment: Lumbar Spine Decompression And Fusion At L5 (fifth lumbar spine vertebra) - S1 (first sacral vertebra).

The insurer denied the Lumbar Spine Decompression And Fusion At L5-S1.  The denial is upheld. 

The patient is a female. She presented with lower back pain radiating to the right lower extremity.

MRI (magnetic resonance imaging) and CT (computed tomography) demonstrated spondylolisthesis at L5 (fifth lumbar spine vertebra)-S1 (first sacral vertebra) without nerve root compression.

The patient was taken to elective surgery for L5 (fifth lumbar spine vertebra)-S1 (first sacral vertebra) transforaminal lumbar interbody fusion. Pain management was consulted to assist in keeping the patient comfortable.  The patient ambulated more than 100 feet.  The patient ambulated 250 feet the following day, and her pain was well-controlled, and she was voiding without issue.  Her drain was removed.

No, the Lumbar Spine Decompression And Fusion At L5-S1 was not medically necessary.
This patient has chronic back and leg pain with spondylolisthesis. There is no evidence of an appropriate course of non-operative treatment, including physical therapy. Standard of care for a patient such as this would include such non-operative treatment before considering surgery.  There is no evidence on imaging studies of significant neural compression to warrant the need for surgery.

There is not enough evidence to support the need for this surgery. Standard of care for a patient such as this would include non-operative treatment being attempted first, including physical therapy. No evidence of a trial of conservative care is documented or provided in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is upheld.

The patient is a male with a history of cannabis dependence who presented to the hospital with abdominal pain, nausea, and vomiting. He had no fever or chills. Blood pressure was 135/78 millimeters of mercury (mmHg), pulse 92 beats per minute (bpm), respiratory rate 16 and temperature 98.1. White blood count was normal, at 9.3. Hemoglobin was 13. He was admitted to the telemetry floor as electrocardiogram (EKG) showed first degree atrioventricular (AV) block with PR interval of 406 milliseconds (ms). He was given Zofran for nausea and vomiting. He left the hospital against medical advice. The subject under review is the medical necessity for the inpatient stay. 

Inpatient hospital admission is not required in this case. Per Milliman Guidelines and the algorithm for emergency evaluation of patients with abdominal pain, the patient did not have any critical findings to indicate need for inpatient admission, such as sepsis, appendicitis, or bowel perforation, among other causes.
Indications for inpatient admission for patients with abdominal pain include hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs, identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction), evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours). Inability to maintain oral hydration (e.g., needs intravenous [IV] fluid support) that persists after observation care, suspected toxic megacolon, bacteremia, or procedure needed that cannot be performed on ambulatory basis. None of these situations apply in this case. The patient's abdominal symptoms could have been evaluated at a lower level of care status.