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

Diagnosis:  Leg swelling, neuropathic pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a male, who initially presented to the emergency department for concerns of worsening leg redness, swelling, and pain. The pertinent history included chronic obstructive pulmonary disease, hypertension, asthma, and bilateral inguinal hernia repair with right lower extremity radiculopathy ever since. A computed tomography (CT) angiogram of the right lower extremity was relatively unremarkable. The patient was admitted to the hospital. The admitting physician had an impression of unilateral painful lower limb swelling. The treatment plan included supportive care and resumption of home medications. Neurology consulted and had an impression of neuropathic right inguinal pain secondary to ilioinguinal nerve entrapment. Recommendations were to increase home gabapentin and consider tizanidine as needed for muscle spasms. General surgery consulted, did not recommend surgical intervention, and recommended consideration for an outpatient ilioinguinal nerve block. The patient was discharged. At issue is the medical necessity of an inpatient admission.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient had a history of an inguinal hernia repair with post-operative chronic right lower extremity radiculopathy and presented with worsening right lower extremity pain and swelling. An extensive laboratory and diagnostic evaluation was performed which were essentially unremarkable for an acute pathological process. Treatment included oral analgesia with additional supportive care. Consultants recommended further management in the outpatient setting. No other issues or complications were documented. Clinical indications for admission to inpatient care were not met. The patient did not have a suspected bone, joint, or muscle infection, compartment syndrome, major injury, limb-threatening injury, severe rheumatologic disease, severe myopathy, or severe pain requiring acute inpatient management.[2]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: facial and tongue swelling

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


This is an adult with a medical history of leukemia, diabetes, and hypertension. The patient was seen in the emergency department with the chief complaint of facial swelling and one episode of vomiting. There was no edema, rash, or facial flushing. The physical examination revealed that he tolerated his secretions, there was marked swelling of his lower lip, and swelling of the base of his tongue. The examination was unable to visualize the posterior pharynx, Trismus and stridor was not observed.  A flexible endoscopic procedure was conducted at bedside which found swelling of the epiglottis but not of the vocal cords.

The patient was diagnosed as having Suspect angiotensin converting enzyme (ACE) angioedema. He was admitted and the appropriate management was given which included close observation for airway dysfunction. A repeat flexible endoscopic procedure was conducted on day 2 of the admission, which found some epiglottic swelling without vocal cord swelling. The patient was then transferred to the medical intensive care unit (MICU) for airway monitoring. His condition improved prior to discharge.

The patient had signs of angioedema as observed on endoscopy of edema of the epiglottis. This was recognized by the attending physician who transferred the patient to the MICU for airway monitoring. This action was consistent with the recommendations in the peer reviewed   literature and the Milliman Care Guidelines (MCG) 26th edition, which states that epiglottitis is an indication for patient admission.

The peer reviewed literature is consistent with the need for airway observation for patients with angioedema.  The patient was noted to have epiglottic swelling on the day 3 of the admission which mandated further observation until he had no more symptoms. 

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 inpatient hospital admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (code: 64628)
The insurer denied Intraosseous Basivertebral Nerve Ablation (code: 64628).
The denial is upheld.

The patient is an adult female with chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, home exercise, and radiofrequency ablation. The patient has failed multiple medications including potent opiate medications. Magnetic
resonance imaging (MRI) shows Modic changes only at T12 (twelfth thoracic vertebra), per the attached report. Physical exam does not reveal any neurological injury.

The health plan should not cover the Intracept procedure.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an adult female who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, home exercise, and
radiofrequency ablation. The patient has failed multiple medications including potent opiate medications. Magnetic resonance imaging shows Modic changes only at T12, per the attached report, not at the requested level of L3-4 (lumbar three to four). Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic-related chronic low back pain. It has been shown effective in randomized controlled trials with five-year results. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient is not documented to have failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternative sacroiliac injections do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (code: 64628)
The insurer denied Intraosseous Basivertebral Nerve Ablation (code: 64628).
The denial is upheld.

The patient is an adult female with low back pain that began several years ago. Her past treatments include home exercise, physical therapy, Tylenol, diclofenac gel, Medrol dose back, Naprosyn, oxycodone, Topamax, and tizanidine. Her pain is rated 9/10 on a visual analog scale as of an office visit six months ago. Magnetic resonance imaging (MRI) of the lumbar spine from last year shows Modic type 2 endplate change at T12 (twelfth thoracic vertebra), Schmorl's nodes at L5-S1 (lumbar five to sacral one), and new left posterior paraspinal musculature edema at L5 to sacrum suggestive of muscle strain. The request for Intracept at L2-4 (lumbar two to four) was denied coverage by the health plan as experimental/investigational. The denial is being appealed.
The health plan should not cover the requested health service.
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 requested health service. Additional studies/trials are necessary to determine efficacy as compared to other conventional therapies. The requested health service or treatment has not been proven to be more beneficial than any standard treatment for the patient's condition or disease. Other standard treatment options that exist in the medical literature may include nonopioid medications (i.e., non-steroidal anti-inflammatory drugs NSAIDs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor treatments), 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: Intraosseous Basivertebral Nerve Ablation (code: 64628)
The insurer denied Intraosseous Basivertebral Nerve Ablation (code: 64628).
The denial is upheld.

This patient is an adult female. The appeals letter notes that the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of
vertebrogenic pain identified by Modic type changes on magnetic resonance imaging (MRI). She had experienced pain and failed treatment for greater than six months. Prior treatments include activity, modification, home exercise, physical therapy, and medication. Six months ago, the patient presented with bilateral back pain going into the legs. Her pain is aching, with tightness, is deep, has pressure, and is spasmodic, and throbbing. The patient previously had bilateral radiofrequency ablation with 80% (percent) improvement. Exam of the lumbar spine showed decreased range of motion with tenderness and tight muscle bands. Facet loading test is positive bilaterally. The health plan should not cover the requested health service. Based on the documentation provided, the requested procedure is not recommended in this case. Although the patient has a history of chronic low back pain, it is not clear why the requested procedure is being requested, since the patient had 80% (percent) improvement from prior radiofrequency ablation. Additionally, MRI (magnetic resonance imaging) results did not support the areas being treated. As
such, the request is not considered medically appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: knee surgery
Treatment: Steroid Injection and Nerve Block 
The insurer denied Steroid Injection and Nerve Block 
The health plan's determination is overturned. 

The patient is a female who underwent a total knee replacement. She had epidural anesthesia for her surgery, and nerve block (adductor canal block) for postoperative pain management. 

Steroid Injection and Nerve Block were medically necessary for this patient. 
Knee replacement surgery is associated with significant amount of postoperative pain especially immediately after the surgery. Uncontrolled postoperative pain may impede early ambulation and surgery recovery that may lead to increased postoperative complications.
There are well-designed clinical studies to show the efficacy and safety of adductor canal block (ACB) for early postoperative pain management in patients undergoing total knee arthroplasty. ACB was associated with better ability to ambulate and quadriceps strength. ACB is safe with decreased postoperative pain and analgesic consumption, and may enhance the rehabilitation program. Based on current clinical studies, the requested procedure was medically necessary for postoperative pain control.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperhidrosis of Axilla
Treatment: Botox
The insurer denied Botox.
The determination is upheld.

This is a female patient with axillary hyperhidrosis, for which it was reported that oral glycopyrrolate and topical Drysol were used for two months. However, the paid claims history and the clinical documentation provided do not support this treatment history, with only 1 milligram (mg) /day of glycopyrrolate being noted and no Drysol. At issue is the medical necessity of Botox.
The patient has not tried and failed standard, first-line topical and oral treatments (such as Drysol and properly dosed Robinul) prior to use of Botox. Botox is therefore not medically inappropriate, but it is not medically necessary. First-line therapies are not contraindicated for this patient and are often used in addition to Botox injections in that they are not mutually exclusive from Botox injections, consistent with standards of care [1-5]. Botox is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is upheld.

This patient is an adult female. She presented to the emergency room with shortness of breath. She has a past medical history of asthma and schizophrenia. In the emergency room, the patient's heart rate was 113, respiratory rate was 27, temperature was 98, blood pressure was 110/78, and oxygen saturation was 100%. Labs results found white blood cell count was 8.8 and blood urea nitrogen/creatinine (BUN/Cr) was 10.3/0.7. Chest X-ray was unremarkable. While still in the emergency room, the patient was treated with full mask bi-level positive airway pressure (FM BIPAP), intramuscular (IM) epinephrine, intravenous (IV) magnesium, IV (intravenous) methyl prednisone, and nebulization with albuterol and ipratropium. The patient was admitted for asthma exacerbation. Her symptoms improved in 
emergency room according to the admission note. She was on nasal cannula 2 liters. Her shortness of breath (SOB) resolved. She was discharged the next day.

The inpatient admission was not medically necessary.

The patient was admitted with shortness of breath. Her symptoms improved in emergency room. The patient only required a few breathing treatments and intravenous steroids. She had no problem in oral intake. There was no indication that her condition was worsening, such as requiring more frequent breathing treatments, requiring higher oxygen or requiring breathing support, or any evidence of infection. The chest X-ray was reported clear. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and hematemesis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
The patient has a history of alcohol abuse and presented with abdominal pain and hematemesis. She was afebrile and the vitals signs were stable. There was mild epigastric tenderness but no rebound or guarding. The hemoglobin was 14.5. The international normalized ratio (INR) was normal. She had alcoholic liver disease. Proton pump inhibitor (PPI) therapy was started, and the hemoglobin remained stable. An upper gastrointestinal (GI) endoscopy showed mild inflammation but no active bleeding. It was advised that she could be discharged after the endoscopy. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-180 for Upper Gastrointestinal Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, peptic ulcer with high-risk endoscopic features, severe coagulopathy, variceal bleeding, severe anemia, gastric outlet obstruction, peritoneal signs, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient was drinking alcohol and had hematemesis. She was treated with a PPI and improved. The endoscopy was negative for active bleeding. She could have had the endoscopy performed with observation care. She had liver enzyme elevation but was not in liver failure. She did not meet MCG criteria for admission for Upper GI Bleeding. 

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

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ovarian cancer

Treatment: code 0037U genetic testing

The insurer denied coverage for code 0037U genetic testing.

The denial is overturned.

This is an adult with a history of high-grade serous ovarian cancer. The patient initially received neoadjuvant chemotherapy and cytoreductive surgery, and then carboplatin and paclitaxel chemotherapy. Pathology noted high grade serous carcinoma with minimal treatment response. Involvement included the left ovary, right fallopian tube, and left anterior uterine serosa. There was a follow-up visit after fluorodeoxyglucose (FDG) imaging was done which showed evidence of recurring tumor and increasing carcinoembryonic antigen (CEA). The treating provider is requesting tissue Foundation One CDx testing after evidence of progression.
The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. The use of FoundationOne after recurrence is supported by National Comprehensive Cancer Network (NCCN) and medical literature.

"Tumor sequencing frequently occurs in the setting of advanced cancer to identify potential therapeutic targets. Use of such testing has rapidly increased, with further growth anticipated. Mutations identified on tumor sequencing may be acquired somatically, caused by postzygotic mosaicism, or inherited through the germline. Identification of germline mutations potentially influences treatment of the current cancer, may provide prognostic information about the potential development of future cancers, and has important implications for family members in terms of risk and prevention of disease. (Clark, D. F. et al. 2019).

"The growing use of next generation-sequencing to identify cancer-associated alterations as well as the increasing number of targeted drugs holds promise for better matching patients with cancer with effective therapies. The FoundationOne (F1; Foundation Medicine) test sequences clinical tumor samples to characterize the exons of 315 cancer-associated genes and introns from 28 genes involved in rearrangements" (Kuderer, N. M. et al. 2017).
Code 0037U genetic testing has final approval from the appropriate regulatory bodies for this diagnosis. It is Food and Drug Administration (FDA) approved in this patient's situation.

This patient is a good candidate for code 0037U genetic testing. FoundationOne CDx testing is an appropriate test for this purpose.

Code 0037U genetic testing is the best available treatment for this patient at this time. This is supported by the National Comprehensive Cancer Network (NCCN) in this case to select and plan future treatment. 

The adverse risks are not increased over standard treatment/services.     

In summary, the denial of code 0037U genetic testing should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ovarian cancer

Treatment: code 0037U genetic testing

The insurer denied coverage for code 0037U genetic testing.

The denial is overturned.

According to the medical records, the patient is an adult with ovarian cancer. The attending provider (AP) performed FoundationOne CDx testing. The patient was treated with chemotherapy and surgery with minimal response. The patient's tumor recurred and FoundationOne was performed at that time on a lymph node biopsy.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. The National Comprehensive Cancer Network (NCCN) supports testing for women with this stage of ovarian cancer.
Per The NCCN (2022) "In the recurrence setting, tumor molecular analysis is recommended to include, at a minimum, tests to identify potential benefit from targeted therapeutics that have tumor-specific or tumor-agnostic benefit. More comprehensive testing may be particularly important in less common histologies with limited approved therapeutic options.  It is recommended that such testing be performed on the most recent available tumor tissue."
"The world of molecular profiling has undergone revolutionary changes over the last few years as knowledge, technology, and even standard clinical practice have evolved. Broad molecular profiling is now nearly essential for all patients with metastatic solid tumors. New agents have been approved based on molecular testing instead of tumor site of origin" (El-Deiry, W. S., et al. 2019).
Code 0037U genetic testing does have final approval from the appropriate regulatory bodies for this diagnosis. This testing is an FDA approved companion diagnostic for ovarian cancer.     

The patient is a good candidate for code 0037U genetic testing.     

Code 0037U genetic testing is the best available treatment for this patient at this time. 
  
The adverse risks are not increased over standard treatment services. 

In summary, the denial of code 0037U genetic testing should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.