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

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Surgical Services. 
The insurer denied trigeminal nerve stimulation. 
The denial is overturned.

The patient is a female with refractory trigeminal neuralgia. Treatment with implantation of a peripheral nerve stimulator is the subject of this review. The service was initially denied as experimental and investigational. The patient has tried and failed carbamazepine, gabapentin, amitriptyline, duloxetine, botulinum toxin, and gamma knife surgery. The subject under review is whether the trigeminal nerve stimulation is likely to be more beneficial than any standard treatment for the patient's condition. 

The peripheral nerve stimulator is likely to be more beneficial than any standard treatment or treatments for the patient's disabling condition, trigeminal neuralgia. Trigeminal neuralgia is a condition that causes painful sensations similar to an electric shock on one side of the face. The pain is often severe, disabling, and difficult to treat.
The present patient has tried and failed all standard therapy. This includes anticonvulsants (carbamazepine and gabapentin), antidepressants (amitriptyline and duloxetine), botulinum toxin, and gamma knife surgery for pain relief. None of the standard therapies have been effective.
Controlled trials are lacking examining the use of peripheral nerve stimulators as compared to conventional therapy. This is because peripheral nerve stimulators are generally a last-line therapy. Nonetheless, there is still clinical evidence to support the use of peripheral nerve stimulators for refractory trigeminal neuralgia and facial pain. One series of patients found that there was a durable decrease in the pain response by approximately 50% for one year or more (the duration of the study). The technique has also been examined by two recent meta-analyses that reviewed all of the pertinent literature on the topic. Both of these studies conclude that peripheral nerve stimulation is a safe and promising treatment for refractory trigeminal neuralgia. In the studies examined in the meta-analysis, results were generally positive and there was a decrease in pain and debility following implantation of the peripheral nerve stimulation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Home health care (HHC) - 46 hours/week
The insurer denied HHC/Personal Care - Level 2 Personal Care Services, per 15 minutes increase to 46 hours/week.
The health plan's determination is upheld.

The patient is a female with a past medical history significant for osteoarthritis, knee pain, and memory impairment. Under review is the medical necessity of Home Health Care (HHC)/Personal Care - Level 2 Personal Care Services (PCS). Additional hours were requested by the patient's physician stating the amount of hours do not meet her medical needs due to increased memory impairment. She has had near falls or falls in the community. There are several physician notes stating that the patient needs additional hours for falls and arthritic changes along with memory impairment and assistance with activities of daily living (ADLs).

HHC/Personal Care - Level 2 PCS, per 15 minutes increase to 46 hours/week is not medically necessary for this patient. The hours approved by the health plan are adequate to meet the needs of the patient.

The patient has a past medical history of osteoarthritis with no loss of motor function noted. The Department of Health's uniform assessment tool (UAS) demonstrated no changes with the patient's physical function since her prior assessment. This includes bed mobility, bathing, personal hygiene, dressing upper and lower body, walking, eating, meal preparation, ordinary housework and medication management. The patient does have bladder incontinence but no bowel incontinence. The amount of hours authorized are able to meet the patient's needs. Additional hours would be considered for safety monitoring which is not a medical necessity.

The 36 hours/week of services approved by the health plan are adequate to meet the patient's medical needs. Services beyond 36 hours/week would be considered not medically necessary and for safety/supervision. The tasking tool notes that the patient requires a total of 30 hours/week of services and the patient has been approved for 36 hours/week of services. There was no significant change in the patient's physical function from evaluation noted last year compared to the recent evaluation. It was noted that patient did have some falls at least through her physician report; however, monitoring the patient for prevention of falls without specific treatment for underlying ADLs or instrumental activities of daily living (IADLs) would be considered safety monitoring. The other issues described under the physician notes, which include increased memory impairment and confusion, again would be considered under safety monitoring specifically when no additional ADLs services are required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Palpitations.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

This is a  woman who presented to the emergency department (ED) complaining of palpitations. Her medical history was remarkable for calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome, severe pulmonary hypertension, chronic obstructive pulmonary disease (COPD), deep vein thrombosis and home supplemental oxygen dependence. In the ED, her blood pressure was 108/55 with a heart rate of 160. Her arterial oxygen saturation was 97% on supplemental oxygen (the number of liters/minute was not specified). An electrocardiogram showed atrial fibrillation with a ventricular rate of 159. Chest X-ray showed no acute pathology. 

An inpatient level of care was not medically necessary.

This woman presented to the hospital with atrial fibrillation with a rapid ventricular rate. She was hemodynamically stable and her rhythm spontaneously converted to sinus while she was still in the emergency department. While she did have underlying cardiopulmonary disease, she was well oxygenated on supplemental oxygen (which she used at home) and had no acute complaints once she was back in sinus rhythm. The documentation provided does not indicate that her condition had deteriorated significantly from her baseline. From the daily progress notes, the indication for continued hospitalization once she was documented to remain stable in sinus rhythm is unclear. The documentation provided does not support an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids. 
Treatment: Inpatient admission. 

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

The patient is a with multiple medical comorbidities, including a history of atrial fibrillation on anticoagulation, diabetes mellitus, hypertension, congestive heart failure, and uterine fibroids complicated by menorrhagia.  The patient presented to the emergency department (ED) for evaluation of uterine bleeding and was noted to be anemic. At the time of presentation, she had stable vital signs, a non focal exam and received a blood transfusion. She was discharged. 

No, the proposed inpatient hospital admission was not medically necessary. 

The patient presented with stable vital signs, a non focal exam and although she has multiple medical comorbidities, all of them are chronic and the patient did not have any conditions that would have required acute inpatient level of care. The patient had stable vital signs, she was afebrile, and was able to ambulate, and tolerate an oral diet and oral medications.  She did not have acute bleeding that required inpatient level of care. Thus, the inpatient level of care was not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient. 
The patient had stable vital signs, she was afebrile, and was able to ambulate, and tolerate an oral diet and oral medications.  The patient did not have acute bleeding that required inpatient level of care. Thus, the inpatient level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heartburn.
Treatment: esophagogastroduodenoscopy (EGD).
The insurer denied the esophagogastroduodenoscopy (EGD).
The denial is upheld.

The patient is a female with heartburn, worsening over a few weeks despite Pepcid. She has not failed proton pump inhibitors, and does not have heartburn associated with vomiting, weight loss, dysphagia, melena or gastrointestinal bleeding. The attending physician (AP) is requesting an esophagogastroduodenoscopy (EGD).

No, the proposed esophagogastroduodenoscopy (EGD) is not medically necessary.
According to the community standard of care, and literature, esophagogastroduodenoscopy (EGD) is medically necessary in the evaluation of gastroesophageal reflux disease (GERD) refractory to two months of proton pump inhibitors (PPIs), or associated with worrisome symptoms of weight loss, vomiting, dysphagia, gastrointestinal (GI) bleeding or anemia. As the patient has a few weeks of heartburn despite Pepcid, and has not failed proton pump inhibitors, and as the heart burn is not associated with worrisome symptoms of weight loss, vomiting, dysphagia, gastrointestinal bleeding or anemia, the requested esophagogastroduodenoscopy (EGD) is not medically necessary.

Yes, as it is not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism spectrum disorder and attention deficit hyperactivity disorder. 
Treatment: Speech Therapy. 

The insurer denied the Speech Therapy. 
The determination is overturned. 

The patient has been diagnosed with autism spectrum disorder and attention deficit hyperactivity disorder (predominantly hyperactive type). These diagnoses were made by a pediatric neurologist. 
The patient is described as having extreme hyperactivity, a short and fleeting attention span, significant distractibility, and difficulty following directions. He has challenges with social interactions at home and in the community. He struggles with conversing with peers, taking on the perspective of others, and regulating his emotions and frustrations. He is able to ask and answer questions, but his conversational interactions are brief, and he is unable to participate in longer dialogues. 
On the Westby Developmental Play Scale, he had extremely brief, single step play actions.  
Speech therapy aimed at improving social pragmatic development, self-regulation and executive functioning is recommended. Whether this therapy is medically necessary is the issue for review. 

The requested speech therapy services [current procedural terminology (CPT) 97129, 97130, 98960] are medically necessary for treatment of the patient's medical condition. The patient has autism and attention deficit hyperactivity disorder. He is having significant difficulties with social interaction, and he is at risk of being bullied as a result of his impairments in the appropriate social use of pragmatic language. Maiano et al [1] estimate that 44% of children with autism are bullied at school. This is frequently due to their difficulty interacting appropriately with others. 
Helland [2] recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism, and that further development of therapy plans and interventions targeting pragmatics is strongly needed. Loukusa et al [3] discuss methods of exploring deficits in pragmatic language in children with autism using 1) the Pragma test, 2) the Social Interaction Deviance Composite (SIDC) of Children's Communication Checklist-2 (CCC-2), and 3) the Theory of Mind subtest of the Developmental Neuropsychological Assessment, Second edition (NEPSY-II). The results showed that children with autism differed from typically developing children in questions demanding context utilization.
In its most recent Guidelines on the Identification, Evaluation and Management of Children with Autism Spectrum Disorder (ASD) published by the American Academy of Pediatrics [4], the authors describe that: 
"All children with ASD should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. "
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: breast cancer.
Treatment: proton beam therapy.
The insurer denied proton beam therapy. 
The health plan's determination is upheld.

This is the case of a female patient who presented with right (R) breast cancer. She underwent chemotherapy followed by a mastectomy. She was recommended adjuvant radiation therapy (RT) to chest wall and nodal area using Proton beam therapy. 

The requested Proton Beam Therapy (PBT) is not medically necessary for this patient.
The generally accepted treatment for this clinical scenario is intensity modulated radiation therapy (IMRT). Proton beam is being evaluated under NCI (National Cancer Institute) sponsored trials. Until the results are available, this treatment is not the standard of care. The National Comprehensive Cancer Network (NCCN) guidelines does not mention or indicate the use of proton beam radiation therapy (PBRT) for the treatment of breast cancer. Current published evidence does not allow for any definitive conclusions about the safety and efficacy of proton beam radiation therapy. The report of ASTRO's (American Society for Radiation Oncology) emerging technology committee also does not include proton therapy for breast cancer.
Proton beam therapy is an emerging technology which has been used in past few years to treat several clinical conditions. However, there is no clinical published data to support its superior clinical outcome compared to other routine 3D-CRT (Three-dimensional conformal radiation therapy) or intensity modulated radiation therapy (IMRT) techniques. Most published studies are small studies from single institutions which do not provide long term outcome of proton beam compared to conventional established photon radiation therapy (RT). These studies suggest improved dosimetric coverage with less side effects. However, there is no clinical published study comparing proton versus (vs) photon to conclude any advantage of proton over established RT techniques. Thus, it is not possible to draw any conclusion of any advantage of proton over photon beam RT in breast CA (cancer).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain.
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient has a history of immune compromise and presented to the emergency department with complaints of right-sided abdominal pain for 2 days. The patient also complained of diffuse muscle aches, chills, and dysuria. 

Vitals on presentation included a temperature max 101.6, Fahrenheit (F) blood pressure of 126/93, heart rate (HR) of 130, respiratory rate of 15, and oxygen saturation 99% on room air. Laboratory results included white blood cell count of 7.8, hemoglobin of 14.3, hematocrit of 6.2, creatinine of 1.11, and glucose of 130.

The patient was admitted for diffuse abdominal pain. He was treated with intravenous fluids and intravenous antibiotics (vancomycin and Zosyn). Computed tomography (CT) scan revealed possible proctitis with enlarged perirectal lymph nodes. Gastroenterology was consulted for a diagnostic sigmoidoscopy. The patient left the hospital against medical advice. 

According to documentation, the patient presented with fever and abdominal pain. The patient was febrile (101.6F) with tachycardia (HR-130) with unclear source of infection requiring additional diagnostic evaluation and treatment. Based on above findings in an immunocompromised patient, hospital 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 admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Pain and High Blood Pressure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male for which an inpatient level hospitalization is under review. There was history of hypertension, diabetes, hyperlipidemia, and he presented with elevated blood pressure. His blood pressure was 227/99. This was noted in a follow-up office visit with his podiatrist after a recent toe amputation for diabetic foot issues. 

The patient's other vital signs were essentially normal. The electrocardiogram (ECG) was reported as non-acute. The potassium was 6.1. The patient was administered intravenous antihypertensive medications in the emergency department; he subsequently improved to 158/80. He was in no acute distress. The creatinine was 1.7. A chest x-ray was reported as normal. The patient was transition to oral blood pressure medications, which were adjusted. The blood pressure normalized while in the emergency department. The elevated potassium was successfully treated and normalized. The patient's renal ultrasound was normal.

No, the proposed inpatient hospital admission was not medically necessary.
This patient presented with hypertension that normalized and remained stable.  There were no mental status changes, acute neurologic or coronary syndrome, seizure, congestive heart failure (CHF), aortic dissection, renal failure, need for prolonged intravenous medications, administration of high risk medications requiring ongoing in-hospital monitoring, or recurrent severe hypertension. In this setting an inpatient level hospitalization, compared to for example observation, has not been established as standard of care towards improved hypertension related outcomes. As such it is considered not medically necessary in this case.

Yes, the health plan acted reasonably, which sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatigue and shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient in this case is a female with a history of gastric cancer status post resection and also a history of iron deficiency anemia.  She presented to the emergency department with fatigue and shortness of breath. 

The patient's physical exam was unremarkable and vital signs were normal.  The patient had noted no apparent bleeding prior to admission. The patient's complete blood count (CBC) was notable for hemoglobin of 5.5 grams per deciliter (g/dl). She was admitted and transfused two units of packed red blood cells. She was seen by hematology during the admission and outpatient follow up was recommended.  The patient was discharged the following day.

No, the proposed inpatient hospital admission was not medically necessary.
This patient was found to have symptomatic anemia and was treated with packed red blood cell transfusion.  She was not actively bleeding at the time of admission.  She was not hemodynamically unstable.  No other acute medical issue was present at the time of admission. Acute care inpatient admission was not medically necessary in this case.  Transfusion of blood does not require acute care admission and could have been performed in the outpatient setting safely for this patient.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: sinusitis.
Treatment: sinus surgery.
The insurer denied sinus surgery (CPT 31298, 31295, 31254 and 30117). 
The health plan's determination is overturned in part.  CPT codes (31298, 31295, 31254) are indicated. CPT code 30117 is not indicated.

The patient is a female with recurrent acute sinusitis. She had 6-7 sinus infections in a year. Medical management included multiple courses of antibiotics, nasal steroids, nasal antihistamines, oral steroids, and decongestants. A CT(computed tomography) scan of the maxillary sinus showed opacification, thickening of nasofrontal ducts, ethmoid sinuses, and sphenoid sinuses. Exam revealed deviated septum, turbinate hypertrophy, and middle meatus narrowing.

The balloon sinuplasty CPT codes (31298 and 31295, 31254) are likely to be more beneficial than standard treatment because they do meet the criteria for chronic sinusitis (thickening noted on CT scan). In addition, the patient's anterior ethmoidectomy was indicated for the chronic sinus disease (noted on CT scan). Balloon sinuplasty is an option in the treatment of sinusitis that has failed appropriate medical therapy. Evidence is best for limited disease in patients with CRSsNP affecting the frontal, sphenoid, and maxillary sinuses. Because BSD can be performed in the office setting, it can be a viable therapeutic alternative in patients with comorbidities who are unable to tolerate general anesthesia.

CPT code 30117 is not likely to be more beneficial in this case. Septal swell body reduction has not been shown in well-designed, long-term studies to be an effective treatment for nasal obstruction. This procedure is not considered standard of care.
The patient had recurrent acute sinusitis refractory to medical management with CT scan evidence of sinus inflammation. Balloon sinuplasty and ethmoidectomy are considered standard of care treatment for medically refractive acute sinusitis. The patient failed medical management thus there were no reasonable medical alternatives. Balloon sinuplasty and ethmoidectomy have been shown in well-designed studies to be a safe and effective treatment for recurrent acute sinusitis.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: sinusitis
Treatment: sinus surgery
The insurer denied sinus surgery (CPT 31298, 31295, 31254 and 30117). The health plan's determination is overturned in part.  CPT codes (31298, 31295, 31254) are indicated. CPT code 30117 is not indicated.

The patient is a female with a history of recurrent sinus infections. Per the letter from the provider, the patient had 6-7 episodes of sinusitis in a year- she has required multiple courses of antibiotics. She also failed to improve with nasal steroids, oral steroids and antihistamines. Per the office note, the patient has had a prior sinus surgery. Intranasal exam at that time showed normal nasal mucosa, narrowing of the middle meatus, inferior turbinate hypertrophy and left septal deviation.
A computed tomography (CT) of the sinuses showed diffuse mucosal thickening in the paranasal sinuses.