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

Diagnosis: Skin tags on the neck
Treatment: Current Procedural Terminology (CPT) code 11200-removal of up to 15 skin tags by any method
The insurer denied coverage for Current Procedural Terminology (CPT) code 11200-removal of up to 15 skin tags by any method.
The denial is overturned.

According to the documentation submitted, this is an adult with a history of skin tags on the neck. The patient presented to the Dermatologist's office for irritated skin tag cryodestruction. The patient had skin tags. 

The insurer has denied coverage for removal of skin tags, multiple fibrocutaneous tags removal of skin tags, multiple fibrocutaneous tags in any area; up to and including 15 lesions as not medically necessary. In a Final Adverse Determination letter, they stated that there is no documentation that the patient did not have a skin lesion excision or other surgery needed, as indicated by 1 or more of the following: 1. Melanoma; 2. Other malignant tumor; 3. Benign lesion that is causing significant functional impairment; 4. Benign tumor with recurrent infection not responsive to nonsurgical therapy; 5. Severe hidradenitis suppurativa with tracts or abscesses; 6. Skin or tissue grafting needed. The requested service is denied based on Milliman Care Guidelines using the guideline of Wound and Skin Management GRG. 

The patient is appealing. In an appeal letter, the Dermatologist stated that the patient has skin tags that get stuck on undergarments and bleed through clothes. It is medically necessary to remove the skin tags.

The patient has a diagnosis of irritated skin tags on the neck.  The clinical documentation indicates that the lesions are raised, painful, and bleeding.  The dermatologist treated the lesions with cryodestruction and billed Current Procedural Terminology (CPT) code 11200-removal of up to 15 skin tags by any method.  The request is to determine whether treatment of these lesions is medically necessary.

Based on the submitted documentation and the billing criteria for CPT (Current Procedural Terminology) code 11200, the use of cryosurgery destruction is medically necessary to treat irritated skin tags which are raised, bleeding, and painful as documented by the clinical notes and appeal letter.  The use of CPT code 11200 is intended to be for the use of removal of skin tags.  The documentation which indicates that these lesions are irritated, painful, and bleeding is sufficient to demonstrate that their removal is medically necessary.  As such, the use of CPT code 11200 is appropriate, and its use in the clinical scenario documented is medically necessary due to the symptomatic nature of the lesions.  The appeal is reversed.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for removal of skin tags, multiple fibrocutaneous tags removal of skin tags, and multiple fibrocutaneous tags in any area; up to and including 15 lesions is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional/High Cholesterol
Pharmacy/Prescription Drugs/Repatha
The health plan denied the requested treatment as not medically necessary. The health plan's determination is upheld.

The patient is a woman with hyperlipidemia. No medical records were provided for review. Per the external appeal application, she has been intolerant to statins and ezetimibe; the statins and the doses tried were not specified. Per the application, Repatha reduced her cholesterol level from "just under 400" milligrams per deciliter (mg/dl) to 209 mg/dl. Presumably, this refers to her total cholesterol level. The patient's low density lipoprotein (LDL) cholesterol level was not mentioned.

The medical necessity for Repatha is at issue.

Based on the limited clinical information provided, I uphold the determination that Repatha is not medically necessary in this instance.

Based on the limited clinical information provided, Repatha cannot be determined to be medically necessary in this instance.

Repatha (evolocumab) is a member of a class of lipid lowering drugs called PCSK9 inhibitors. It is Food and Drug Administration (FDA) approved for use in adults with established cardiovascular disease to reduce the risk of myocardial infarction, stroke, and coronary revascularization; as an adjunct to diet, alone or in combination with other low-density lipoprotein cholesterol (LDL-C)-lowering therapies in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia to reduce LDL-C; and as an adjunct to other LDL-C-lowering therapies in patients with homozygous familial hypercholesterolemia to reduce LDL-C. Current guidelines endorse its use in patients with clinical atherosclerotic cardiovascular disease (ASCVD), familial hypercholesterolemia (FH) or baseline LDL-C levels of 190 mg/dl or greater whose levels remain above goal despite maximally tolerated statin therapy. The limited information provided does not document that this woman has ASCVD, FH, or a baseline LDL-C level of 190 mg/dl or greater. Moreover, since the statins she has previously been intolerant to were not specified, nor were their dosages, it cannot be determined that she has complete statin intolerance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dog Bite.
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a toddler male who presented with concern for infection of the hand from a dog bite from three days earlier. The dog is a friend's dog and reported to have up to date shots including rabies. The patient was seen in the emergency department and had the wound irrigated and ointment was placed. He was given a prescription for Augmentin. He received a dose at night and in the morning. The patient's x-ray was negative. The mother saw the wound for the first time the day of admission and brought him back to the emergency department due to increased swelling. The dog has not shown any signs of rabies. 
On exam, radial and ulnar pulses were 2-plus. Swelling on the dorsum of the left hand and erythema on the palm just proximal to the digits was noted. There was a laceration between digits three and four that did not probe to bone. There were punctate scabbed lesions to the dorsum on the skin overlying the proximal phalanges of left hand digits three and four. There was no odor. The patient was afebrile. The plan was for complete blood count, comprehensive metabolic panel, wound culture, C-reactive protein, erythrocyte sedimentation rate, prothrombin time, partial thromboplastin time (PTT), and Unasyn intravenous every 6 hours. The patient's white blood cell count was 13.8. On the next day, the patient's swelling improved. Pediatric orthopedics was consulted. The mother reported no drainage and swelling improving. Wound culture was positive for gram positive cocci. C-reactive protein was 1. The patient was continued on intravenous Unasyn. Plan was to soak in normal saline with a few drops of betadine daily. On day #3, the patient was discharged. He was continued on oral antibiotics. 

The proposed treatment was not medically necessary. 

Based on the information presented, the proposed treatment was not medically necessary. The patient was treated for the same injury several days prior. Per the hospital note the patient received the first dose of antibiotics on the evening before admission and the morning of the admission. The mother then saw the patient. She had not seen the injury when it first occurred. The patient had an evolving wound with inadequate time for antibiotic treatment to be deemed failure. The patient 
had received two doses of antibiotics. The patient was moving his digits and has good perfusion. There was no suggestion of necrosis or deep tissue infection requiring parenteral antibiotics. 
Most dog or animal bites can be managed as outpatient.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

Diagnosis: atrial fibrillation
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a man with a history of atrial fibrillation, anticoagulated with Xarelto, who was seen in the emergency department with A-fib (atrial fibrillation) with rapid ventricular response (RVR). The patient was asymptomatic with a rapid heart rate but complained of cold-like symptoms with a cough but no fevers or chills. 

An inpatient stay is not medically necessary for this patient. The patient has uncontrolled A-fib with RVR in the setting of known arrhythmia, anticoagulated with Xarelto. After administering intravenous (IV) diltiazem in the emergency department, the heart rates remained controlled in the 80s. Cardiology planned for outpatient cardioversion procedure. There was no hemodynamic compromise, and the patient was largely asymptomatic. In regards to the infiltrates on the computed tomography angiography (CTA) of the chest, the medical team was concerned about pneumonia. Still, the patient had no oxygen requirement, no dyspnea symptoms, normal white blood cell count after 24 hours, and normal procalcitonin, indicating a low likelihood of pneumonia. Blood cultures were negative; there were no complicated pleural effusions. Based on the pneumonia diagnosis, the Curb-65 and pneumonia severity index scores were too low to qualify this presentation for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and dizziness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male who was hospitalized for chest pain and dizziness. His past medical history included hypertension, hyperlipidemia, anemia, gout, diabetes, gastroesophageal reflux disease (GERD), major depressive disorder, chronic obstructive pulmonary disease (COPD), vertigo, congestive heart failure (CHF) with ejection fraction (EF) of 40-45%, rheumatic heart disease, mechanical mitral and aortic valve replacements, and Coumadin therapy. The patient's vitals were stable. His blood pressure was 161/86 and heart rate was 59. There was two-plus (2+) pedal edema on exam. Electrocardiogram showed atrial fibrillation, rate 55, and 
nonspecific ST-T changes. Brain natriuretic peptide (BNP) was elevated to 327. The clinical impression was heart failure with preserved ejection fraction and benign positional vertigo. Treatment included intravenous Lasix and two liters nasal oxygen. He underwent a transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), and myocardial perfusion study. He progressed and was deemed stable for discharge and outpatient cardiac catheterization. The requested coverage for inpatient hospital admission was denied based on the patient's policy. The patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer-reviewed medical literature, including the Milliman Care Guidelines (MCG) criteria for Chest Pain, #M-89 and Heart Failure (ORG: M-190), criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received, including treatment for mild congestive heart failure, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD)
Treatment: Esophagogastroduodenoscopy (EGD) (Code: 43239)
The insurer denied: Esophagogastroduodenoscopy (EGD) (Code: 43239)
The denial is overturned.

The patient is an adult female with longstanding epigastric pain and gastroesophageal reflux disease (GERD). Her symptoms have persisted despite treatment with Protonix for many months. The provider requested an esophagogastroduodenoscopy (EGD). The esophagogastroduodenoscopy was denied, as it was not known if the patient had failed two months of acid suppression therapy or had alarm symptoms of weight loss, vomiting, early satiety, gastrointestinal (GI) bleeding, or anemia.

The esophagogastroduodenoscopy was medically necessary.

An esophagogastroduodenoscopy is medically necessary in patients who have failed two months of acid suppression therapy. As the patient has longstanding gastroesophageal reflux disease that has not been responsive to over two months of acid suppression therapy with Protonix, the esophagogastroduodenoscopy was clinically appropriate, accepted standard of care, and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and sore throat
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is upheld.

The patient is an adult female without significant past medical history. She was hospitalized with fever and sore throat that was thought likely to be related to a viral infection. The patient's vital signs were notable for temperature 101.3, pulse 103, normal blood pressure and respirations, and oxygen saturation 100% on room air. Labs were notable for white blood cell count 18, lactate 1.17, normal creatinine, negative COVID and influenza testing, urinalysis with trace leukocyte esterase. Notes indicate a diagnosis of "sepsis from unknown source." She was given fluids, antibiotics, and acetaminophen/Toradol. The patient had clinical improvement. Blood cultures were negative. She was evaluated by infectious disease consultant team. She was discharged on day #3 in stable condition with oral antibiotics.
The inpatient hospitalization was denied coverage by the health plan, who noted that the patient could have been managed in a lower level of care. The facility appealed the denial, arguing that the patient's workup and treatment "could not have been done in 
the outpatient setting. Clearly there was no feasible way to discharge the patient." The health plan upheld the denial, noting again that the medical records showed that the patient could have been placed in observation and monitoring. This denial is being appealed.

The inpatient admission was not medically necessary.

The documentation does not reflect clinical findings that support the need for acute inpatient level of care per the medical literature and evidence-based guideline entitled "Sepsis and Other Febrile Illness, without Focal Infection (M-160)" from MCG (Milliman Care Guidelines) 26th edition. Specifically, there was no evidence of hemodynamic instability, bacteremia, hypoxemia, altered mental status, failure of outpatient treatment, new coagulopathy, persistent tachypnea, persistent dehydration, evidence of end organ dysfunction that is persistent or severe, core temperature less than 95, parenteral antimicrobial regimen that could only be performed on an inpatient basis, or isolation that could not be performed in the outpatient setting. This patient was hemodynamically stable, had no critical derangement in labs, had quick improvement with initial treatment, and was able to be transitioned to oral antibiotics for discharge within the observation timeframe. Treatment could have safely and effectively been provided at a lower level of care. Therefore, the inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth
Treatment: D6010 Implant Placement: Tooth 18, Tooth 19, Tooth 30, and Tooth 31, D6057 Custom Abutment: Tooth 18, Tooth 19, Tooth 30, and Tooth 31, and D6059 Abutment Supported Porcelain Fused to Metal Crown (High Noble Metal): Tooth 18, 
Tooth 19, Tooth 30, and Tooth 31
The insurer denied D6010 implant placement: tooth 18, tooth 19, tooth 30, and tooth 31, D6057 custom abutment: tooth 18, tooth 19, tooth 30, and tooth 31, and D6059 abutment supported porcelain fused to metal crown (high noble metal): tooth 18, tooth 19, tooth 30, and tooth 31.
The denial is overturned.

The patient is an adult female requesting benefits for four implants, abutments, and implant crowns. The prior denial was due to guidelines saying implants are not covered if there are eight teeth in occlusion already. Also, there was a recommendation to use a lower partial denture to replace the patient's missing teeth.

The proposed treatment is medically necessary.

The patient wears a full upper denture that is ill fitting. Since she has no natural upper teeth of her own, she has less than the "8 tooth rule" dictates. She has no natural teeth touching between her upper and lower jaws. Also, the patient has tried partial dentures several times with no success. Her dentist states she get blisters, bleeding, and pain when wearing the partial, so she gave up. The patient's doctor states the patient has diabetes and digestion issues. These cannot be helped by not eating properly. The patient is not a candidate for a fixed bridge either, since she has no posterior anchor teeth. All of her other lower teeth are sound, which is mandated in the guidelines. The patient's only option is to get the four implants, abutments, and implant crowns. There is no other way to treat her. This case has medical necessity.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure.
The denial is upheld.

The patient is an elderly male with low back pain for 5 months. Past treatments include physical therapy and home exercise program. His condition has been characterized by a VAS (Visual Analogue Scale) score between 2/10 and 4/10. A recent Oswestry Disability Index score was obtained with a result of 27%. Lumbar MRI (magnetic resonance imaging) from last year shows severe L4-5 (lumbar four to five) spinal stenosis, moderate spinal stenosis L2-4 (lumbar two to four), L5-S1 (lumbar five to sacral one), multilevel nerve impingement, and grade 1 spondylolisthesis at L5-S1 (lumbar five to sacral one).
The request for Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the Intracept procedure.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry-funded, high-quality, large prospective studies are needed to confirm these findings.
At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such, the health plan should not cover the Intracept procedure. Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e., NSAIDs [nonsteroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor 
treatments), and interventions (i.e., epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions.)
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is upheld.

The patient is an elderly male. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebral genic pain identified by degenerative endplates on MRI (magnetic resonance imaging). The pain has been ongoing for greater than 6 months, and the patient has failed treatment for greater than 6 months. The patient continues with home exercise. The patient has tried medication management and physical therapy. Per a note dated five months ago, the patient presented with low back pain ongoing for 5 months. The pain is non-radiating. Examination revealed decreased range of motion and pain with extension and facet loading. Straight leg raise is negative. The patient describes the pain as constant, shooting and sharp.

The health plan should not cover the Intracept procedure.

Based on the documentation provided and per current studies, the requested procedure is not recommended at this time. Although the patient has a history of chronic low back pain, there was lack of documentation of the patient having tried and failed all conservative treatments. Based on the MRI (magnetic resonance imaging) report, the patient had multiple findings that could be the cause of the patient's symptoms. There was lack of documentation of any facet injections versus medial branch blocks versus neurosurgical consultations.