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

Diagnosis: Spinal Stenosis.
Treatment: Ambulatory surgery - lower back surgery.
The insurer denied ambulatory surgery - lower back surgery.
The determination is upheld.

The patient has low back pain which radiates into the bilateral posterior thighs and bilateral knees and numbness into the bilateral feet. The pain can be as high as 10 out of 10. The patient's medications include hydrocodone. The patient's diagnoses include lumbar stenosis with neurogenic claudication. The plan for is for a minimally invasive lumbar decompression (MILD) procedure. At issue is whether this is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The requested 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 low back pain which radiates into the bilateral posterior thighs and bilateral knees and numbness into the bilateral feet. The MILD (minimally invasive lumbar decompression) describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. This procedure is not supported by evidence-based guidelines. Currently, additional randomized controlled trials in appropriate patients are needed to compare this new procedure with established alternatives. In one randomized controlled trial (RCT) to evaluate the minimally invasive procedure percutaneous laser discectomy (even though it was Food and Drug Administration [FDA] approved 24 years ago), there was no indication that this minimally invasive surgery is superior to open surgical techniques.

Overall, the proposed health service or treatment ambulatory surgery - lower back surgery is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal Stenosis.
Treatment: Ambulatory surgery - lower back surgery.
The insurer denied ambulatory surgery - lower back surgery.
The determination is  overturned.

The patient has low back pain with radiating pain down the bilateral posterior legs with numbness in the feet. His pain level is 4/10 to 10/10. His pain is exacerbated with standing and ambulation. He underwent an epidural injection, which provided several months of pain relief. The physical exam (PE) revealed motor strength 5/5 in the lower extremities. Magnetic resonance imaging (MRI) revealed severe spinal stenosis at lumbar (L) 3-4 from ligament of flavum hypertrophy. The patient was recommended to have a minimally invasive lumbar decompression (MILD) procedure for this spinal stenosis.

The issue is whether the MILD procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This patient has spinal stenosis with neurogenic claudication. MRI confirmed his stenosis from ligament of flavum hypertrophy. He had failed conservative treatment including an epidural injection. The MILD procedure is a minimally invasive image-guided intervention designed to remove hypertrophied ligament of flavum, which can alleviate symptoms of neurogenic claudication and lead to improvements in pain and function. There is strong clinical evidence to prove the efficacy of this intervention for spinal stenosis secondary to ligament hypertrophy. This patient is a good candidate for the MILD procedure. The alternative is open surgery with laminectomy, which is associated with more risks and complications. In addition, laminectomy surgery will require general anesthesia, which carried additional risks related to anesthesia. In light of these clinical facts, MILD procedure is the appropriate next step treatment.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative Colitis.
Treatment: Hydrocortisone acetate 25mg (milligram) suppositories.
The insurer denied Hydrocortisone acetate 25mg suppositories.  
The determination is upheld.

The patient has ulcerative colitis (proctitis). He presented with a history of internal hemorrhoids, and was started on Analpram hydrocortisone (HC) 1-2.5%. A colonoscopy showed internal hemorrhoids and ulcerative proctitis, and fecal lactoferrin was elevated at 551.6 micrograms per milliliter (mcg/mL). Hydrocortisone acetate 25 mg suppositories for the treatment of ulcerative colitis (proctitis) are under review. The request was not approved as the formulary alternatives Procto-Pak (hydrocortisone) cream 1% and hydrocortisone cream 2.5% have not been attempted.

The request for hydrocortisone suppositories is not supported by current medical literature, and hydrocortisone creams are not supported either. American College of Gastroenterology guidelines for the treatment of ulcerative colitis do not recommend corticosteroid suppositories [1]. American Gastroenterological Association guidelines for the treatment of mild to moderate Ulcerative Colitis (as in this case, with limited disease extent) state that rectal 5-aminosalicylate therapy are superior to rectal corticosteroids for inducing remission in randomized controlled trials, adding "In patients with mild-moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy, the American Gastroenterological Association (AGA) suggests using mesalamine enemas rather than rectal corticosteroids" and "Patients who place a higher value on avoiding difficulties associated with mesalamine enemas and a lower value on effectiveness may reasonably select rectal corticosteroid foam preparations" rather than suppositories [2]. Additionally, the guidelines state that in patients "who choose rectal therapy over oral therapy, the AGA recommends using mesalamine suppositories", with a recommendation for rectal corticosteroids only in patients who are intolerant of or refractory to mesalamine suppositories [2]. The guidelines state that no trials of maintenance rectal corticosteroids were identified, and their long-term effectiveness and safety are unknown ("rectal corticosteroids have not been studied for maintenance of remission in ulcerative proctitis. Given concerns about long-term safety and effectiveness of corticosteroids for this indication, use of mesalamine suppositories is preferred") [2]. A review article concluded that topical corticosteroids including hydrocortisone have not proven effective for maintaining remission in distal colitis [3]. Another concluded that hydrocortisone is not effective for maintaining remission in ulcerative colitis [4]. Even higher doses of hydrocortisone, including 100 mg daily, have not proven effective [5].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive supranuclear palsy.
Treatment: Home health care.
The insurer denied Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift) for a Total of 168 Hours per Week. 
The health plan's determination is overturned. 

The patient is a male with past medical history of progressive supranuclear palsy, benign prostatic hyperplasia (BPH), hypertension, hyperlipidemia, osteoarthritis, restless leg syndrome, macular degeneration, and urinary incontinence who had been assigned PCA (personal care aide) services. The patient is at maximum assistance with tasks of meal preparation, ordinary housework, managing medication, stairs, shopping, transportation, and bathing while extensive assistance with tasks of managing finances, phone use, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The patient's neurologist provided a letter requesting an increase in home health aide hours of assistance to 24 hours/day, 7 days/week. 

Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift) for a Total of 168 Hours per Week is medically necessary for this patient.

There is documentation through the patient's neurologist's letters and office notes of progression of the patient's progressive supranuclear palsy. The patient was attending physical therapy and was having adjustment in medication but despite this had worsening cognitive and functional status. The patient's neurologist documented the need for turning and repositioning every 2 hours as well as frequent toileting to prevent skin breakdown. The patient's daughter is unable to provide informal help for all of the hours outside of currently approved PCA services. The family can no longer afford private pay aide services. The patient has 24-hour care needs and the insurer should not have utilized a task based assessment to calculate PCA hours. The patient requires assistance with walking, locomotion, transfer toilet and toilet use and therefore has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The nature of the patient's neurologic condition will not cause improvement in assistance needs with IADLs and ADLs over time. 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, the requested services are indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis.
Treatment: Remicade 15 milligrams per kilogram (mg/kg) every 5 weeks.

The insurer denied Remicade 15 milligrams per kilogram (mg/kg) every 5 weeks.  The determination is overturned.

The patient has ulcerative colitis (pancolitis). He has failed mesalamine and sulfasalazine. Remicade every 8 weeks had been ineffective. Remicade every 5 weeks has been effective, with a recent colonoscopy showing disease control and normal C-reactive protein; he is reportedly in remission on this dose. At issue is the medical necessity of Remicade 15 milligrams per kilogram (mg/kg) every 5 weeks for the treatment of his ulcerative colitis (pancolitis).

The request to continue Remicade 15 mg/kg every 5 weeks for the treatment of ulcerative colitis (pancolitis) is supported as medically necessary. Remicade (infliximab) is Food and Drug Administration (FDA)-approved and recommended for the treatment of ulcerative colitis; increased doses are commonly required during maintenance therapy with infliximab, and it can be effective [1,2]. The Phase III ACT-2 trial of infliximab for ulcerative colitis showed higher response at week 8 with 10 mg/kg dosing [2]. Specifically, this Phase III randomized double-blind placebo-controlled trial demonstrated a 69% rate of remission at 8 weeks with infusion of 10 mg/kg, rather than 64% with infusion of 5 mg/kg. Other large studies have shown that the disease can be maintained in a majority of cases with an increase of the dose [3,4]. The American College of Gastroenterology guidelines for the management of ulcerative colitis support the requested increase in Remicade dosage in patients with uncontrolled disease [5]. The use of dose escalation can prevent complications and colectomy, and empiric dose escalation can be effective [6,7]. De-escalation of dose can result in relapse and complications [8]. The patient has failed lower doses of Remicade, and has been in remission on the current dose. For these reasons, an increase in the dose to 15 mg/kg every 5 weeks is supported by current medical literature and guidelines. If the dose is decreased, or if Remicade is discontinued (even if an alternative is attempted immediately), there is risk for a disease flare, uncontrolled disease, or uncontrolled disease manifesting as dysplasia and leading to colon cancer. For these reasons, the request for Remicade 15 mg/kg every 5 weeks is supported as medically necessary for the treatment of this patient's ulcerative colitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Other/Heartburn
Treatment: Surgical Services (All).
The health plan denied the requested esophagogastroduodenoscopy (EGD). 
The health plan's determination is upheld.

The patient is a female with heartburn who underwent an upper endoscopy. Only mild gastritis was identified. The progress notes state the patient had occasional heartburn associated with weight gain. The patient has no dysphagia, nausea or vomiting.
At issue is the medical necessity for the requested esophagogastroduodenoscopy (EGD).

I uphold, in whole, the health plan's determination of medical necessity.

No. Per guidelines, the patient did not need an endoscopy. The first indication for endoscopy would be to screen for Barrett's, however this patient is in a low-risk group and therefore this indication is not applicable. The second reason to do an endoscopy would be if this patient had red flag symptoms. This includes dysphagia, nausea, vomiting, bleeding or anemia. The patient has none of these symptoms. In my opinion, there was no evidence-based reason to perform an upper endoscopy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose veins.
Treatment: Vein treatment (procedure code 36471).
The insurer denied coverage for vein treatment (procedure code 36471).
The denial is upheld.

This case involves a female with a history of bilateral lower extremity symptomatic varicose veins with the left extremity being worse than the right. A lower extremity venous reflux study noted posterior thigh clusters of varicosities ranging in size from 2.9 to 4.0 mm (millimeters) on the right. There was no evidence of deep venous reflux.

The patient was seen for an evaluation. She reported a longstanding history of venous insufficiency including a previous left leg stripping and phlebectomy.  She reported aching, tiredness, fatigue, and throbbing in the lower extremity. The patient reported that her symptoms interfered with her daily activities. She stated that the symptoms would at times wake her up from sleep. She was elevating her legs. She had a family history of venous insufficiency. She had worn compression in the past with minimal relief. Her left leg reflux study demonstrated no evidence of truncal reflux but refluxing varicosities. Her right leg reflux study demonstrated no evidence of truncal reflux.  The patient was status post left leg phlebectomy. She was doing well with the exception of some small varicosities and enlarged reticular veins that caused her discomfort despite compression bilaterally. The exam findings of the patient noted that the bilateral lower extremities were warm and well-perfused. There were small varicosities and enlarged reticular veins and spider veins bilaterally. The provider recommended bilateral injection sclerotherapy.

Per the referenced sources, sclerotherapy is indicated for bleeding or ruptured superficial varicose veins, recurrent or residual symptomatic superficial varicosities after vein stripping or ablation, for skin ulcer with surrounding large superficial varices that are not associated with saphenofemoral valve incompetence, and for symptomatic superficial varices. In this case, the patient had varicosities ranging in size from 2.9 to 4.0 mm on the right. Reportedly, her vein measurements ranged from 2.1 to 4.4 mm on the left. The patient endorsed heaviness, aching, itchiness, and burning. The patient had utilized compression stockings and elevation with ongoing symptoms. She was status post left leg phlebectomy. The provider recommended bilateral leg sclerotherapy CPT (current procedural terminology) 36471 X 6. While a reflux study was provided for the right lower extremity, a reflux study was not provided for the left lower extremity to confirm the presence of varicosities with large size. Therefore, the medical necessity of the treatment cannot be established. As such, the denial of coverage for vein treatment (procedure code 36471) was appropriate and is upheld.

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

The insurer's denial of coverage for vein treatment (procedure code 36471) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope.

Treatment: Inpatient emergency admission.

The insurer denied coverage for inpatient emergency admission.

The denial is overturned.

The patient presented to the emergency department after an episode of syncope. The patient was postoperative day three after conversion of a sleeve gastrectomy to a gastric bypass. Vital signs on presentation were a blood pressure of 112/63 millimeters of mercury (mmHg) and a pulse of 81 beats per minute (bpm). Hemoglobin was noted to be 6.9. The patient was transfused one unit in the emergency department. A computed tomography (CT) scan of the chest, abdomen, and pelvis was negative for any acute pathology. Repeat hemoglobin was noted to be 7.4 and 6.8 the following day. The patient was then transfused an additional two units of blood. Per Milliman Care Guidelines (MCG) guidelines, admission for anemia is indicated in patients with recurrent syncope or near syncope or clinically significant signs or symptoms that are severe or persist despite observation care (example (e.g.), transfusion, volume replacement). [1] The patient's hemoglobin did not increase appropriately after initial transfusion. Clinical documentation notes that the patient presented after a syncopal episode and was noted to be hypotensive by Emergency Medical Services (EMS). Based on provided clinical documentation, the inpatient admission was medically necessary. 

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

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

Diagnosis: Pancreatitis.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

The patient had a history of pancreatitis and presented with abdominal pain after drinking alcohol. She was afebrile and the vital signs were stable. There was only mild abdominal tenderness with no abdominal rebound or guarding. There was no leukocytosis. The abdominal CAT (computed tomography) scan was read as chronic pancreatitis and that the pancreatic fat stranding had diminished from the prior study. There was a lipase of 298. 

Clinical indications for admission for Pancreatitis (MCG [Milliman Care Guidelines] M-250) include having acute pancreatitis or chronic pancreatitis. This patient had chronic pancreatitis. The abdominal CAT scan was consistent with chronic pancreatitis, and the residual inflammation around the pancreas had decreased from the prior study. For patients with chronic pancreatitis, indications include inability to maintain oral hydration, evidence of infection, hemodynamic instability, severe dehydration, severe vomiting not responsive to antiemetics, stage 3 acute renal failure, altered mental status, and severe electrolyte abnormalities. The patient did not have these conditions.

This patient had chronic pancreatitis. She required intravenous (IV) hydration and pain medications. This treatment could have been given with observation status. She did not meet MCG criteria for acute care for chronic pancreatitis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not 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 an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Systemic lupus erythematosus (SLE); autoimmune hepatitis
Treatment: Opzelura 1.5% (percent) Cream (Pre-Service)
The insurer denied the Opzelura 1.5% Cream (Pre-Service).
The denial is upheld.

The patient is a female who is requesting coverage of Opzelura 1.5% (percent) cream for treatment of a malar rash secondary to systemic lupus erythematosus (SLE).

No, the health plan should not cover the proposed Opzelura 1.5% cream.

Opzelura 1.5% cream is not medically necessary for this patient. Opzelura is a topical application that is Food and Drug Administration (FDA) approved for treating atopic dermatitis. There is nothing from a clinical and/or research standpoint to suggest that this drug may be efficacious for this patient's skin rash. It is therefore considered unproven for treatment of this patient's condition.

The malar rash is a symptom of the patient's underlying disease process. The clinical information indicates that she has failed treatment with oral corticosteroids, mometasone, azathioprine and hydroxychloroquine. There is no medical reason why the patient cannot attempt treatment for the rash with the alternatives offered by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld.

This is a male with a history of asthma who had been coughing for 2 days following a trip to a water park. On the day prior to the admission, he was noted to have shortness of breath and intercostal retractions which did not improve with albuterol, so his mom decided to bring him to the emergency room (ER) for additional treatment. There was a history of a previous admission to the PICU (pediatric intensive care unit) for asthma. The child had been prescribed an inhaled steroid in the past, but the mother was not using this treatment.

In the ER he was noted to have inspiratory and expiratory wheezing and an increased respiratory rate with intercostal retractions. There was a history of his vomiting on 3 occasions. He did not have a low pulse oximeter reading and did not require treatment with oxygen. Following oral prednisone, three treatments with duoneb, and a subsequent albuterol he was improved and no longer in acute respiratory distress. The physical exam showed he was breathing comfortably with scattered occasional wheezes bilaterally. He was eating and drinking well and in no acute distress. He was not felt to be in status asthmaticus, and the plan was for an admission to the hospital for continued treatment with albuterol every 4 hours. The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child has a history of one asthma admission in the past and he did not improve with one treatment with albuterol in the home. He did improve with treatment in the ER and he was no longer experiencing increased work of breathing or respiratory distress. He was not having low oxygen saturations and did not require oxygen supplementation. The plan for continued treatment with albuterol every 4 hours could have been continued at home and the child could have been safely discharged on inhaled steroids and albuterol with a follow up appointment with pediatric pulmonology.

It is not consistent with the standard of care to admit a child with asthma who responded to ER treatment just so the child could be seen in consultation with the pediatric pulmonologist to restart daily anti-inflammatory therapy for persistent asthma. He was stable enough to be safely discharged on albuterol every 4 hours to be administered in the home. 

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

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