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

Diagnosis: Head laceration

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is a male patient with a medical history of diabetes mellitus and hypertension. The patient presented to the Emergency Department (ED) with a head laceration. The patient was oriented to place, date, president, but was unsure how he received a laceration on his head. The patient denied drinking alcohol but admitted smoking cigarettes. However, the patient's wife at the bedside admitted that every year, the patient went to the neighbor's Super Bowl party and drank alcohol. The notes also indicated that on that day, the patient was found with facial abrasions and posterior scalp laceration; the person that found the patient was unsure if the patient had lost consciousness or not. In the ED, the patient's vital signs included a blood pressure of 104/63, a heart rate of 88, and respirations of 17 and oxygen saturation of 94% on room air. The patient underwent a laceration repair for a 4 cm laceration with 6 staples. The patient's Glasgow Coma Scale score was 15 out of 15. On exam, there were no neurologic deficits. Based on trauma workup and radiologic imaging, the patient's intracranial injury was noted to be stable. Neurosurgery wanted to observe the patient but did not recommend any intervention. The patient was admitted and was discharged home the same day in stable condition.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient's neurological exam was normal and the patient's trauma workup was unremarkable. The patient was alert and oriented, and was hemodynamically stable. According to MCG guidelines for traumatic brain injury (M-78), admission is clinically indicated for conditions including hemodynamic instability, severe/persistent altered mental status, Glasgow coma scale <13, worsening neurologic function post presentation, new clinical signs/symptoms of neurologic deterioration, evidence of increased intracranial edema, presence of intracranial infection, and/or need for inpatient wound care. However, this was not the case for this patient. The patient was admitted and discharged on the same day after a brief period of observation. Based on MCG guidelines, this patient could have been observed in the Emergency Department or Observational level of care. Thus, inpatient admission was not medically necessary. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient admission.

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

This is a male patient with medical history of prostate cancer. The patient was to start on radiation therapy. The patient presented to the Emergency Department with complaints of dizziness for several weeks. The patient's electrocardiogram (EKG) revealed T-wave inversions in leads II, III, aVF, V4-V6. The patient's troponin level was negative. The patient's blood pressure was 164/105 and the heart rate was 69. The patient denied chest pain, palpitations, diaphoresis, tinnitus, or any prodrome-like symptoms. The patient was admitted to the hospital for near syncope. The patient was to be treated with intravenous (IV) fluids and medications and was to undergo evaluation with a Holter monitor and orthostatic blood pressures. The patient's orthostatic blood pressures were negative. The patient underwent a computed tomography (CT) scan of the head, which was unremarkable. The patient's chest x-ray was also negative for acute process. The cardiology consult recommended an echocardiogram, which revealed left ventricular ejection fraction of 66% and a grade 1 (mild) left ventricular diastolic dysfunction. The patient was noted to be stable and was discharged. 

Based on the review of the medical record, inpatient admission was not medically necessary for this patient. An evaluation of "near syncope" is not a reason for hospital admission. This can be evaluated as an outpatient or observational setting. Clinical condition that would have warranted this patient to inpatient admission is possible stroke or possible cardiac event. However, in this case, the patient did not have any symptoms suggestive of a stroke. The patient's computed tomography (CT) scan also ruled out this etiology. The patient's electrocardiogram (EKG) showed inverted T-waves, but the patient had negative troponin values, and no other cardiac related signs or symptoms. With regard to the blood pressure, in absence of acute end organ damage, this is managed as an outpatient. Based on the review of the clinical guidelines, inpatient admission was not medically necessary for this patient. 

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied INTRACEPT procedure. 
The denial was upheld in whole.

The patient is a female with complaints of chronic low back pain. The patient has had epidural injections, medications, as well as physical therapy and other associated modalities. Magnetic resonance imaging (MRI) of the lumbar spine showed multilevel degenerative changes. There is a request for INTRACEPT Procedure. The subject under review is whether or not this procedure will be more beneficial for this patient than any standard treatment.

The health plan's determination is upheld.

The patient has complaints of low back pain. There is a request for INTRACEPT Procedure, which is a form of radiofrequency (RF) ablation of the basivertebral nerve (BVN). There are insufficient large-scale, randomized, controlled studies showing the efficacy of this procedure. There are insufficient large case studies and long-term follow-up for chronic pain patients after this procedure. As such, the proposed health service or treatment INTRACEPT 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Achalasia.
Treatment:  POEM (per oral endoscopic myotomy).

The insurer denied the POEM (per oral endoscopic myotomy).  The denial is overturned. 

The patient is a female with h/o (history of) new onset of choking sensation and difficulty swallowing, and dysphagia both to solids and liquids.  Due to poor oral intake, she has lost approximately 10-15 lbs of weight. 

The patient was evaluated by GI (gastroenterology) and underwent barium swallow, which revealed dilated, aperistaltic esophagus with distal obstruction, c/w (consistent with) the diagnosis of achalasia.

High-resolution manometry was done, and it was consistent with type II achalasia, with EGJ (esophagogastric junction) outlet obstruction with 100% incomplete clearance, failed peristalsis on each swallow, and panesophageal pressurization of greater than 20%, high IRP (Integrated Relaxation Pressure) and LES (lower esophageal sphincter)/EGJ pressure, c/w the diagnosis of type II achalasia.

The patient underwent POEM (per oral endoscopic myotomy) without any complications.

Yes, the health plan should cover the POEM for the management of this patient with achalasia.

Achalasia is an uncommon primary motor disorder of the esophagus, characterized by disorganized peristalsis and insufficient relaxation of the lower esophageal sphincter (LES).  These abnormalities impede food passage across the LES into the stomach, causing symptoms that include dysphagia, regurgitation, and/or chest pain.  Treatment targeting disruption of the LES leads to improvement or resolution of symptoms in the vast majority of patients.

Currently, three main LES-directed treatments are offered to patients with achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM).  PD is the most common procedure performed worldwide for achalasia; it involves outpatient endoscopy, passage of a dilating balloon across the LES, and robust dilation to disrupt the sphincter.  Dilation can be performed as a single procedure alone or as part of a sequential treatment plan involving multiple dilations, and it is only temporarily effective.

Yes, the POEM procedure to treat achalasia is likely to be more beneficial than PD as discussed above, and comparable to HRM.  However, POEM is preferred over HRM, as it is less invasive, with lower morbidity and mortality.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Achalasia.
Treatment:  POEM (per oral endoscopic myotomy).

The insurer denied the POEM (per oral endoscopic myotomy).  The denial is overturned. 

The patient is a female with achalasia.  Her doctor is requesting treatment with POEM (per oral endoscopic myotomy).

Yes, the health plan should cover the 43499 - POEM for achalasia.

Yes, the 43499 - POEM for achalasia is likely to be more beneficial.

Medical literature supports that POEM is a safe and effective treatment for achalasia, and has a positive effect on health outcomes. 

Per Inoue, H., et al. (2015), "Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used.  Adverse events were rare (3.2%), and there were no mortalities.  Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM.  Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy." 

Per Patel, K., et al. (2016), "In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms.  Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality, with additional investigation of more novel metrics such as EndoFLIP and objective measures of reflux (e.g. impedance studies) pre- and post-treatment." 

Lastly, per Zaninotto, G., et al. (2018), "Recommendations: we conditionally recommend POEM as an effective therapy (control of symptoms) for achalasia both in short- and medium-term follow-up with results comparable to Heller myotomy for symptom improvement." 

The upper endoscopy was actually the POEM that was performed.  The manometry was referenced in previous records and was consistent with the other imaging in that it confirmed the diagnosis of achalasia.

As POEM is a safe and effective treatment for achalasia, and is less invasive than Heller myotomy, and as it has a positive effect on health outcomes, it is standard of care for this patient.  The health plan should, therefore, cover the requested POEM for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Plaque Psoriasis.
Treatment:  Cosentyx.

The insurer denied the Cosentyx.  The determination is upheld.

The patient has moderate to severe psoriasis (more than 10% body surface area involvement) that includes the scalp and groin, as well as nail pitting.  The patient has tried and failed compounded sulfur, clobetasol ointment and solution, and halobetasol, as well as phototherapy.  The patient has a family history of cancer.  The health plan denied Cosentyx as "the preferred drugs are Humira, Stelara, Tremfya, Cimzia, and Skyrizi.  You did not show us that you have tried and failed one preferred drug."
At issue is the medical necessity of Cosentyx.

The Cosentyx is not medically necessary.  The patient has no documented treatment failure with, or true medical contraindication to the preferred drugs, Humira, Stelara, Tremfya, Cimzia, or Skyrizi.  All of these medications are medically appropriate for this patient, taking into account his health and family history.  Cosentyx is not proven to be superior to all other formulary alternatives for this patient's clinical scenario, as per comparative, controlled studies.  Modern dermatology literature [2-5] supports use of the health plan preferred medications as similarly efficacious to the requested Cosentyx, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario.  Therefore, as per current medical standards of care, Cosentyx is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced dementia 
Treatment: Personal care services 24 hours/day, seven days/week (live-in) 

The insurer denied the Personal care services 24 hours/day, seven days/week (live-in). 

The patient is a female with a history of dementia, and urinary and fecal incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in Personal Assistance Services to 24 hours/day, seven days/week (live-in) to offer increased ADL support. 

Yes, the proposed treatment of an increase in Personal Assistance Services to 24 hours/day, seven days/week (live-in) is deemed medically necessary. 

Recent documentation from the patient's physician indicates that due to progressive functional/clinical decline, the currently approved plan of eight hours/day, five days/week and 12 hours/day, two days/week, 64 hours total is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services to 24 hours/day, seven days/week (live-in) is deemed medically necessary.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Chron's Disease
Treatment: Pentasa 
The insurer denied the Pentasa.
The denial is overturned. 

The patient is a female with Crohn's disease of the small bowel and colon. She has been doing well on Pentasa. The physician is requesting continuation of Pentasa. 

Yes, the proposed Pentasa is medically necessary.

The patient has small bowel and colonic Crohn's, and has been maintained on Pentasa.  Per the provided medical policy, in order for criteria of Pentasa to be met, the patient must have tried and failed Lialda and Apriso. Medical literature supports that Pentasa is pH dependent and is therefore released more in the small bowel than Lialda and Apriso.  Pentasa is therefore more effective than those agents for the treatment of small bowel Crohn's disease. Therefore, the proposed Pentasa is medically necessary, and the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/gastrointestinal
Inpatient hospital

Diagnosis: GI Bleed
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient was a female with medical history of hypertension, anemia secondary to uterine fibroids which resolved with hysterectomy, possible G6PD deficiency, and migraines. She presented to the emergency department with over ten episodes of rectal bleeding, and concurrent abdominal cramping pain; she had diarrhea the night before. She had taken three Imodium prior to arrival. Vital signs were notable for elevated blood pressure of 155/83 mm Hg. Physical examination was notable for left lower quadrant abdominal tenderness, with mild guarding. Labs showed unremarkable blood count and chemistry. Computed tomography scan of the abdomen and pelvis with angiogram showed market thickening of the descending colon with surrounding inflammatory changes consistent with acute colitis, and no focal contrast pooling to suggest acute bleeding; there was diverticulosis. She was treated with intravenous pantoprazole with drip, famotidine, and fluids. 

The inpatient hospital admission was not medically necessary. The patient had symptoms including abdominal pain, diarrhea, and hematochezia, as well as imaging findings, consistent with acute gastroenteritis or colitis. The standard of care for the treatment of colitis and the evaluation of diarrhea was appropriately performed, including intravenous fluids, empiric antibiotics, and supportive care, and symptoms improved. The patient improved on intravenous antibiotics; there was no protracted fever or hypotension to suggest that antibiotics were ineffective. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. The care which was undertaken, including observation, monitoring, labs, antibiotic administration, specialist consultations, and sitter observation, could have been performed at a lower level of care.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis:  Migraines.
Treatment:  Emgality 120 MG/ML SC SOAJ.

The insurer denied the Emgality 120 MG/ML SC SOAJ.  The determination is upheld.

This patient with a history of headaches, who had to discontinue Topamax secondary to cognitive impairment.  He had been given a sample of Magmalin that worked effectively for 6 weeks.  He had severe debilitating headaches for 2 weeks, with 3 headaches per week that could last for several days, associated with nausea, vomiting, and light sensitivity.  He had side effects available in the past when provided for depression.  It was noted "beta blockers are contraindicated in young males secondary to sexual dysfunction."  He was using Cambia prophylactically.  He had projectile vomiting with the last 2 episodes of migraines.  His neurological examination revealed normal general revealed normal head, eyes, ears, neck, throat (HEENT), neck, cardiovascular, pulmonary, abdominal, musculoskeletal, skin, mental status, cranial nerve, motor, sensory, reflex, gait and cerebellar examinations.  The diagnosis was migraine.  Emgality and Cambia were prescribed.

A review of pharmacy claims indicates the following evidence-based migraine prophylactic medications: verapamil and topiramate.  Other pertinent prescriptions included fluoxetine, aripiprazole, rizatriptan  and dextroamphetamine-amphetamine.  The Emgality is under review for medical necessity.

The Emgality is not medically necessary at this time.  This is a patient with a history of migraine.  He has had a trial and failure of topiramate and verapamil.  He is unable to utilize or tricyclic antidepressants, as he is ongoing treatment with a serotonin specific reuptake inhibitor and aripiprazole.  There are no contraindications to beta blockers.  His provider indicated that beta blockers (propranolol, metoprolol, timolol, nadalol, atenolol) are contraindicated in young men.  This is not the case, and it is not listed as a contraindication in the prescribing information.  It is listed as an adverse reaction.  However, beta blockers are commonly used in young males, and anticipation of an adverse effect does not predict its occurrence.  There is no evidence in the medical literature that a calcitonin gene-related peptide (CGRP) agent is superior to any oral migraine prophylactic therapy with level I evidence of efficacy, such as propranolol and other beta blockers.  The patient is not currently on Emgality with benefit. Antidepressants (amitriptyline, venlafaxine, and venlafaxine ER [extended release]) are contraindicated, due to his current treatment with aripiprazole and fluoxetine, and likewise Depakote would also be contraindicated due to its effects on mood.  However, there is no contraindication to propranolol, and there is no evidence that Emgality is superior to propranolol or other beta blockers for the treatment of migraine prophylaxis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of chronic low back pain secondary to spinal stenosis, diffuse osteoarthritis, associated gait ataxia, Diabetes Mellitus, Hypertension and PTSD (post-traumatic stress disorder). 
Treatment: PCA 42 hours/week 
The insurer denied the PCA 42 hours/week.
The denial is upheld. 

The patient is a male. He has a history of chronic low back pain secondary to spinal stenosis, diffuse osteoarthritis, associated gait ataxia, Diabetes Mellitus, Hypertension and PTSD (post-traumatic stress disorder). Due to impairments related to these conditions, the patient requires assistance for completion of the majority of his ADLs (activities of daily living). An appeal review was requested for potential approval of an increase in Personal Assistance Services to 42 hours/week to offer increased ADL support.

No, the proposed treatment of an increase in Personal Assistance Services to 42 hours/week is not deemed medically necessary. 

The patient is a male with a history of chronic low back pain secondary to spinal stenosis, diffuse osteoarthritis, associated gait ataxia, Diabetes Mellitus, Hypertension and PTSD. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Furthermore, the beneficiary reported a change in function and clinical status after having recent surgery. However, an in home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 35 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation that demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of an increase in Personal Assistance Services from to 42 hours/week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient stay. 
The denial was upheld in whole. 

This is the case of a male who was brought to the emergency department by Emergency Medical Services (EMS) after the patient had been assaulted. It is not known whether the patient lost consciousness. The patient has a significant past medical history for alcohol abuse, hypertension, cirrhosis, hyperlipidemia, and arthritis. The emergency department workup revealed a rib fracture, a slightly displaced nasal tip fracture, and minimally displaced fracture extending to the right upper central incisor/root. His labs showed an Ethanol level of 292.8 and a platelet count of 45,000. He was admitted with telemetry monitoring. He was also seen by facial plastic surgery, who deemed his injury non-operative. He was placed on Clinical Institute Withdrawal Assessment (CIWA) monitoring for possible alcohol withdrawal and also intravenous (IV) antibiotics. He improved and was discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

This is not a medically necessary inpatient stay. This patient had injuries that could be managed at a lower level of care status. He had 1 rib fracture without pulmonary compromise. He had a nasal tip and the oblique fracture extending to the incisor/root, that were non-operative. The antibiotics were switched to Augmentin, which is oral. The patient was not displaying signs of alcohol withdrawal on presentation. With his liver dysfunction and low platelet count, it would be appropriate to admit for monitoring to ensure that the patient did not have bleeding related to his traumas. However, an inpatient setting was not necessary for this monitoring. Had the patient gone into active alcohol withdrawal, displaying the physiology of delirium tremens, then an inpatient admission would have been warranted. However, this patient did not show any signs of alcohol withdrawal on admission and did not require treatment with medication for alcohol withdrawal during the stay.