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

Diagnosis: Left shoulder pain
Treatment: Left shoulder MRI (magnetic resonance imaging - pictures of inside shoulder) x (times) 1
The insurer denied coverage for left shoulder MRI (pictures of inside shoulder) x 1.
The denial is upheld.

This case involves a pre-teenager with a history of left shoulder pain and left wrist fracture. The patient presented for a follow-up visit related to left shoulder pain. The patient reported that the pain in the shoulder had remained consistent. The patient was attending physical therapy regularly. The physical exam findings of the left shoulder demonstrated full abduction and forward flexion. With the arm abducted to 90 degrees, the patient had just over 90 degrees of external rotation. The patient had internal rotation to the mid back. Examination of the right shoulder demonstrated a mild increase in external rotation compared to the left. There was also hypomobility of the right scapula. There was no obvious winging or atrophy. There was no evidence of multidirectional instability. The patient was assessed with a left shoulder sprain. The provider noted that the patient was not improving, and it was unclear why. The provider recommended magnetic resonance imaging (MRI) of the left shoulder. It was stated that a request for MRI of the left shoulder was denied. The request was denied as prior radiographs were not obtained.

Per the cited references, MRI of the shoulder may be indicated to evaluate for ligament, muscle, or tendon injury or tear or other shoulder joint pathology when there are positive provocative exam findings and no response to conservative treatment.  MRI is recommended for chronic shoulder pain of unclear etiology when there are normal findings on plain radiographs and pain has not improved after 6 or more weeks of nonoperative therapy. Imaging may also be recommended after trauma when there are normal findings on plain radiographs and suspected dislocation, labral tear, or rotator cuff tear. 

In this case, the patient had ongoing complaints of shoulder pain despite physical therapy. The provider recommended MRI for further evaluation. However, the documentation did not detail that the patient had plain radiographs that were nondiagnostic. The documentation also did not clearly establish positive provocative exam findings consistent with suspected ligament, muscle, or tendon injury or tear. As such, proceeding with the request is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for left shoulder MRI (pictures of inside shoulder) x (times) 1 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatocellular cancer 
Treatment: Imfinzi
The insurer denied Imfinzi.
The health plan's determination is upheld. 

This is a male with hepatocellular cancer and a confusing treatment history. The patient was previously treated with Opdivo 5 years ago followed by carboplatin plus gemcitabine. He received Lenvima plus pembrolizumab and then received atezolizumab plus bevacizumab. The patient was maintained on oral Lenvima for some time, but apparently progressed.

Imfinzi is not medically necessary for this patient.

Sequential use of immune checkpoint inhibitors following progression on a prior agent in this class has not been demonstrated to be of benefit and is not recommended in the peer reviewed literature nor in national guidelines. While there is evidence of efficacy for durvalumab in hepatocellular patients, this evidence is largely limited to the treatment naive patient population. This patient has received three prior lines of immune checkpoint inhibitors (nivolumab, pembrolizumab, and atezolizumab). For these reasons, the authors of UpToDate do not recommend the use of durvalumab in this clinical scenario. Lacking support for this approach, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Applied Behavior Analysis (ABA) behavior assessment- 12 units. 

The insurer denied the Applied Behavior Analysis (ABA) behavior assessment- 12 units. 
The health plan's determination is overturned. 

The patient is a male with a history of deficits in social emotional reciprocity, impaired eye contact, restrictive repetitive patterns of behavior and deficits in developing, maintaining and understanding relationships. He has had a neuropsychological assessment for the evaluation of autism. 

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

The ABA behavioral assessment is medically necessary for the patient. ABA treatment is the gold standard treatment for individuals diagnosed with autism (Choueiri et. al, 2017 and Linstead et. al, 2017). The patient has a valid diagnosis of autism spectrum disorder. He has had an evaluation using multiple modalities including an autism diagnostic interview, screens for common behavioral issues, observational analysis via mental status and a comprehensive interview to come to the diagnosis of autism spectrum disorder. The patient has a valid autism diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 criteria which is also supported by the evaluation that was completed. 

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially presented to the emergency department for concerns of right upper quadrant pain and right flank pain. Pertinent history included computed tomography (CT) abdomen/pelvis that revealed pneumobilia and a right upper quadrant (RUQ) ultrasound (US) that revealed a dilated common bile duct (CBD) of 1.1 centimeter (cm) and possible gallstone. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care.  The patient presented with right upper quadrant and flank pain. Initial evaluation documented the patient as afebrile, hemodynamically stable, without systemic signs of inflammation ,and without elevated liver enzymes. Initial examination noted a positive Murphy's sign without peritoneal signs. Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) did not reveal biliary obstruction or stones. The hepatobiliary iminodiacetic acid (HIDA) scan was positive for cholecystitis. Treatment plan included analgesia and empiric antibiotics. Following observation care, the patient was documented as tolerating a regular diet without issue, ambulating without difficulty, and pain was controlled. No other issues or complications were documented. The patient was discharged with oral antibiotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

The patient is an adult male active smoker who presented to the emergency room with flank pain. The imaging of the chest, abdomen, and pelvis showed innumerable nodules in the lungs concerning for infection such as tuberculosis (TB) or metastatic cancer. The patient was also found to have COVID-19 infection. The patient was admitted to the acute in-hospital level of care for further work-up. The patient was seen by Infectious Disease and Pulmonary specialists. The patient underwent blood work as well as sputum collection to rule out tuberculosis. The acute hospitalization is denied due to lack of medical necessity. 
This denial is being appealed.

The proposed treatment was not medically necessary.

The patient was found to have abnormal computed tomography (CT) of the chest and asymptomatic COVID-19 infection. The patient had sputum collection for tuberculosis and blood work performed to rule out tuberculosis. The patient was seen by Infectious Disease and Pulmonology who recommended outpatient work-up of abnormal computed tomography of the 
chest. The patient did not receive any treatment that could not have been provided safely and effectively at a lower level of care. The proposed treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine fibroids
Treatment: Transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors)
The insurer denied coverage for transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors)
The denial is upheld

According to the clinical documentation provided for review, the patient is an adult. The patient presents with symptomatic uterine myomas, a history of abnormal Pap (Papanicolaou) smears in the past who has heavy uterine bleeding with menses and bladder pressure from the myomas and has been recommended treatment by transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors). The treating provider is requesting plan approval for transcervical uterine ablation of leiomyomas.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

Use of this treatment lacks efficacy and safety data from long-term, prospective and randomized trials. There are no data to support use of this treatment, it is not a standard of care and it is not supported by professional organizations. Therefore, the request is denied and not appropriate. 

"The preliminary results from the first 160 treated women in SAGE (postmarket global registry involving up to 50 sites and up to 500 women who select TFA (Transcervical fibroid ablation) with the Sonata system for treatment of symptomatic uterine fibroids) suggest broad applicability of TFA (Transcervical fibroid ablation) to a wide range of fibroid types and sizes and an excellent safety profile. These initial results corroborate those from previous clinical trials, as well as over 600 commercial cases worldwide. The wide repertoire of fibroid types treated in SAGE, including transmural, intramural, and subserosal fibroids, are not generally accessible to operative hysteroscopy. The registry will follow women for 5 years, after which a comprehensive characterization of long-term outcomes of TFA will be possible. SAGE represents the largest known study of TFA for uterine fibroids and will generate up to 2500 patient-years of long-term outcomes data. Final results from the SAGE registry are anticipated to be published in 2026" (Christoffel, et al (and others), 2021).

In summary, the denial of transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine fibroids
Treatment: Transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors)
The insurer denied coverage for transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors)
The denial is upheld

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

Transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors) needs final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for transcervical uterine ablation of leiomyomas.

Transcervical uterine ablation of leiomyomas is not the best available treatment for this patient at this time.

The adverse risks are increased over standard treatment/services.

The requested service is unlikely to be more beneficial than any of the standard treatments/procedures for this patient.

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 postprocedure, 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 3 years of follow-up.

The use of the Sonata system in this patient's case is not appropriate as the patient has a fibroid greater in size than the 5 centimeters (cm) size that is reported in all the published studies about the efficacy and safety of Sonata. In other words, there is no data about the effectiveness of the sonata system in patients with larger fibroids. As such the requested procedure is not considered appropriate for this patient and the denial should be upheld.

The patient with a 10.5 cm fibroid will benefit much more from a tested procedure like a myomectomy that will remove the fibroid with immediate relief of the symptoms. 

In summary, the requested procedure is not appropriate for this patient as there is no evidence of improvement in health outcomes.

In summary, the denial of transcervical uterine ablation of leiomyomas (use of ultrasound and heat to remove benign uterine tumors) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rectal bleed. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 
 
This case involves an adult who presented to the emergency department with reports of rectal bleeding. The patient endorsed a past medical history significant for hemorrhoidectomy 9 days prior. He reported severe rectal bleeding and was brought in by ambulance as a transfer from another hospital. Blood was bright red with no reported vomiting or nausea and no pain or discomfort. The report stated that the patient had undergone surgery and had episodes of bloody stools with a syncopal episode at home. While at the initial facility, the patient had another large bowel movement and another syncopal episode. On assessment, the patient was alert and oriented x4 with normal color for ethnic group and skin was warm and dry. Vital signs were stable.  Laboratory values showed low hemoglobin 9.8, hematocrit 28.7, and red blood cell count at 3.31. The treating physician ordered dextrose 30% injectable and glucagon injectable and the patient was admitted to the colorectal service for closer monitoring of his blood count, laboratory values, and overall clinical prognosis. The patient was subsequently discharged the following day in stable condition.

According to the Milliman Care Guidelines (MCG), clinical indications for admission to inpatient care for those individuals who have lower gastrointestinal bleeding include those who have 1 or more of the following to include hemodynamic instability, ongoing active bleeding with decreased hematocrit, failure to control bleeding after colonoscopy or findings of require continued hospitalization (for example, high risk for rebleed), coagulopathy that is not quickly reversible, suspected or known ischemic colitis, shock index greater than 1 (shock index equals heart rate divided by systolic blood pressure), anemia as indicated by all the following to include presence of significant clinical findings by 1 more the following such as tachycardia, altered mental status, heart failure, chest pain, exertional dyspnea, or other findings suggesting an adequate perfusion, and observation care treatment with transfusion or volume replacement is judged inappropriate or has been ineffective. Inpatient care may also be indicated for peritoneal signs or the inability to maintain oral hydration that persists despite observation care.

The documentation provided for the review noted the patient had ongoing active bleeding with decreased hematocrit. Given these findings along with the patient's recent surgery, the inpatient stay was appropriate and within the standard of care.

Based on the above, the insurer's denial must be overturned. 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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is overturned.

The patient is an adult female with past medical history of CVA (cerebrovascular accident) on ASA (aspirin), and mixed connective tissue disease. She presented to the ER (emergency room) due to severe right-sided headache occurring for the prior two days. It did not respond to OTC (over-the-counter) medication. She also had similar symptoms from when she had her stroke.

The patient was placed on observation and given IV (intravenous) medications. Neuro checks were done. Symptoms did not improve. She was admitted.

Inpatient admission was medically necessary. The patient had severe headache despite management on observation level. This is one of the requirements for inpatient admission of MCG (Milliman Care Guidelines) 26th edition- Headaches.
Appeal type: Medical necessity
Decision: Overturned

Issue under review: Inpatient admission
Determination: The inpatient admission was medically necessary.

The patient is an adult female with past medical history of CVA (cerebrovascular accident) on ASA (aspirin), and mixed connective tissue disease. She presented to the ER (emergency room) due to severe right-sided headache occurring for the prior two days. It did not respond to OTC (over-the-counter) medication. She also had similar symptoms from when she had her stroke. The patient was placed on observation and given IV (intravenous) medications. Neuro checks were done. Symptoms did not improve. She was admitted. 

Inpatient admission was medically necessary. The patient had severe headache despite management on observation level. This is one of the requirements for inpatient admission of MCG (Milliman Care Guidelines) 26th edition- Headaches.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuromuscular disorder
Treatment: Code 98928 (osteopathic manipulative treatment)
The insurer denied coverage for code 98928 (osteopathic manipulative treatment).
The denial is overturned.

This is a patient that was treated with osteopathic manipulative treatment (OMT) from a licensed doctor of osteopathy. Medical necessity of billing code 98928 (osteopathic manipulation) billed  is currently in review. 

Chart notes document the patient's areas of complaint, examination findings, diagnosis, treatment, treatment plan, and goals with treatment. Documentation supports 8 body regions involved including cervical, thoracic, lumbar, sacral, pelvis, lower extremity, upper extremity, and ribs. Patient had good response.

Code 98928 is considered medically necessary for this patient.

The patient has a neuromuscular disorder. The medical necessity for treatment is clearly documented. Improvement is documented as patient had good response. Documentation received from the health plan clearly indicates billing code 98928 is an allowable and payable code pending documentation that establishes medical necessity. Since documentation attached for review establishes medical necessity, the code is payable. Therefore, the code 98928 is considered medically necessary for this patient.

Per Roberts, A., Harris, K., Outen, B., Bukvic, A., Smith, B., Schultz, A., Bergman, S., & Mondal, D. (2022), "OMT is lower-cost, noninvasive, and highly effective in promoting full-body healing by targeting the nervous, lymphatic, immune, and vascular systems."

Per Licciardone, J. C., Schultz, M. J., & Amen, B. (2020), "Osteopathic physicians in the United States are uniquely positioned to manage chronic pain because their professional philosophy embraces the biopsychosocial model, and they are trained in the use of OMT to complement conventional medical care. Nevertheless, national surveys indicate that men, persons with low levels of education, and non-White and Hispanic patients are significantly less likely to have ever received OMT in their lifetime, and that many osteopathic physicians infrequently use OMT in medical practice. Osteopathic manipulative treatment is most often used by patients with low back and neck pain. Although OMT is considered safe, based on millions of patient encounters over more than a century, there is generally limited evidence on its efficacy for chronic pain. However, there is substantial evidence from systematic reviews, a large clinical trial, and observational studies to support its use in patients with chronic low back pain."

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

The medical necessity for code 98928 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Amyotrophic lateral sclerosis (ALS).
Treatment: Radicava ORS 105 milligrams (mg)/5 milliliters (ml) oral suspension.
The insurer denied Radicava ORS 105 milligrams (mg)/5 milliliters (ml) oral suspension.
The health plan's determination is upheld.  

The patient is a male who has a listed diagnosis of amyotrophic lateral sclerosis (ALS). However, records do not indicate that this diagnosis is established. He presented with difficulties using his hands, and the diagnoses considered have included Hirayama' syndrome, multifocal motor neuropathy and monomelic amyotrophy. Nerve conduction studies and electromyography were thought to not show conclusive, diagnostic abnormalities to establish ALS. The provider has disagreed with this assessment. Given uncertain diagnosis, intravenous Immunoglobulin has been tried. 

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Radicava ORS is not medically necessary for this patient. As discussed above, diagnosis is uncertain. Radicava ORS is proven effective in the high-quality peer-reviewed literature for patients with an established ALS diagnosis based on the Airlie House criteria (El Escorial) criteria, which is not documented in this situation. Radicava is Food and Drug Administration (FDA) approved for ALS, which has not been firmly established.

The health plan's determination of medical necessity is upheld in whole given diagnostic uncertainty.