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



Diagnosis: traumatic amputation

Treatment: Healthcare Common Procedure Coding System (HCPCS) code L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system with Modifier LT left side

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system with Modifier LT left side

The denial is upheld.

The patient is an adult male with complete traumatic amputation at level between knee and ankle, left lower leg. He was advised to be fitted with a lower limb prosthesis with a vacuum pump and a moisture evacuation system. This has been denied based on the peer-reviewed literature which does not support a result of improvement in health outcome. The determination is being appealed.

Literature articles were attached and reviewed.

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

Based upon the peer-reviewed literature there is insufficient scientific evidence to support a result of improvement in the health outcomes using this prosthetic modification. 

At this time, it is not clear whether vacuum pump and a moisture evacuation system provide greater benefit than standard prosthetic suspension. Further studies are needed to evaluate the clinical effectiveness and superiority of prosthetics with elevated vacuum suspension systems versus standard prosthetic systems. Therefore, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

The use of this procedure does not have final approval from the appropriate regulatory bodies.     

This patient is not a good candidate for Healthcare Common Procedure Coding System (HCPCS) code L5781 (Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system) with Modifier LT [left side (used to identify procedures performed on the left side of the body)].     

Healthcare Common Procedure Coding System (HCPCS) code L5781 is not the best available treatment for this patient at this time.     

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

The requested service is not likely to be more beneficial than any of the standard treatments/ procedures for this patient. 


In summary, the denial of Healthcare Common Procedure Coding System (HCPCS) code L5781 (Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system) with Modifier LT [left side (used to identify procedures performed on the left side of the body)] 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 not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: Total Amount of 84 Hours per Week (12 Hours per Day, 7 Days per Week). The health plan's determination is overturned. 

This is a case review for a male with medical history notable for mobility issues. A Uniform Assessment System (UAS) was available for review. The assessment was conducted in person. The patient showed modified independence with cognition, having some difficulty in new situations. For his Instrumental activities of daily living (IADL), he requires total dependence for housework, stairs, and transportation. He requires maximal assistance for meal preparation, medications, and shopping. For his activities of daily living (ADL), he requires total dependence for locomotion. He requires maximal assistance for bathing, hygiene, dressing, toilet transfer, toilet use, and bed mobility. He is frequently incontinent of urine and occasionally incontinent of stool. He uses pullups for incontinence care. Compared to a prior UAS, the patient showed a decline in his functional ability.

The requested Consumer Directed Personal Assistance Program (CDPAP) Services: Total Amount of 84 Hours per Week (12 Hours per Day, 7 Days per Week) is medically necessary for this patient.
The patient is receiving end-of-life care from hospice. His condition has been deteriorating and is not expected to improve. He requires hands-on assistance for all activities of daily living including locomotion, transfers, and toileting. His care needs can be expected to be continuous and unscheduled throughout the day and will include numerous diaper changes to address his incontinence. Furthermore, his recent fall when unassisted is evidence of unmet personal care needs. Therefore, the requested increase to allow him personal care coverage for most of his waking hours is medically necessary and reasonable for the patient. Failure to address his personal care needs could lead to recurrent falls, skin breakdown, and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain.
Treatment: Lumbar Epidural Steroid Injection (62323x1).

The insurer denied: Lumbar Epidural Steroid Injection (62323x1).  The denial is overturned.

The patient is an adult male, who presented with a history of low back pain going down both legs. The pain has been ongoing for two years. The patient reports a worsening of symptoms with difficulty walking for longer than 10 minutes. The patient has tried non-steroidal anti-inflammatory drugs (NSAIDs) for six weeks, as well as a home exercise program via physician for six weeks. The pain is rated as 7/10 and is described as shooting, electric, and radiating. Exam noted diminished range of motion in the lumbar spine. Reflexes and motor strength in the lower extremities are normal. There was a positive straight leg raise and slump test.

The Lumbar Epidural Steroid Injection is medically necessary.

Based on the documentation provided, the request is considered medically necessary in this case. The patient has a history of low back pain with radicular symptoms. It was noted that the patient has pain ongoing for greater than two years. He has tried non-steroidal anti-inflammatory drugs (NSAIDs) as well as a physician-directed home exercise program for greater than six weeks. The patient has positive findings on exam and magnetic resonance imaging (MRI). As such, the request is recommended in this case. The requested Lumbar Epidural Steroid Injection is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Central Nervous System/ Neuromuscular Disorder-Headache
Treatment: Pharmacy/Prescription Drugs-Quilipta
The Health Plan denied the non-formulary prescription medication as not meeting its formulary criteria. The reviewer has upheld in whole the health plan's determination.

The patient is a female with migraine who is prescribed treatment with Qulipta. The drug was denied because the member has not tried and failed the remaining formulary alternatives of Ajovy, Emgality, Aimovig, valproic acid, amitriptyline, venlafaxine, and lamotrigine. Documentation indicates that the member has tried and failed topiramate and nortriptyline. The provider appealed the determination.

The plans formulary includes multiple drugs for prevention of migraine. These include Aimovig, Ajovy, Emgality, valproic acid, amitriptyline, venlafaxine, and lamotrigine. The documentation shows that the member has tried and failed oral migraine preventative therapies. As a result, it is unlikely that the patient will respond to some of the formulary alternatives including valproic acid, venlafaxine, amitriptyline, and lamotrigine.
However, the formulary also contains medication's that are Food and Drug Administration (FDA) approved and literature supported for prevention of both episodic and chronic migraine. This includes the CGRP inhibitors of Ajovy, Aiomovig, and Emgality. There is no medical reason to believe that these drugs would be in effective for the patient. These drugs have been shown to decrease migraine frequency by approximately 50% in controlled trials. The member has not used any of these drugs and does not have an absolute contraindication to the use of these drugs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lumbosacral spondylosis.
Treatment:  Personal Care Services, Level 2: 5 Hours per Day x 7 Days per Week (Total 35 Hours per Week).

The insurer denied Personal Care Services, Level 2: 5 Hours per Day x 7 Days per Week (Total 35 Hours per Week).  The determination is upheld.

This is a female patient with a medical history notable for lumbosacral spondylosis. The patient was approved for 12 hours per week of personal care services. The patient and her care team requested an increase to 5 hours per day, 7 days per week (35 hours per week) and this request was partially denied by the health plan; they did approve an increase to 6 hours per day, 3 days per week (18 hours per week). There were no letters of medical necessity or medical records provided as part of this review.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in her home. She was alert and oriented with periods of forgetfulness. She is able to direct her own care. For her Instrumental activities of daily living (IADLs), she requires maximal assistance for housework and shopping. She requires extensive assistance for transportation, stairs, and meal preparation. She is independent for all others. For her activities of daily living (ADLs), she requires limited assistance for all. She requires contact guidance with ADLs. She is continent of stool and urine. A task tool associated with the UAS recommended 17.7 hours per week to address her personal care needs. Compared to a prior UAS, she showed a decline in functional status in both ADLs and IADLs. At issue is the medical necessity of Personal Care Services, Level 2: 5 Hours per Day x 7 Days per Week (Total 35 Hours per Week).

The requested health service of Personal Care Services, Level 2: 5 Hours per Day x 7 Days per Week (Total 35 Hours per Week) has not been demonstrated to be medically necessary for this patient.

The patient's functional status has declined as outlined in the most recent UAS. The task tool recommended an increase in hours. Although the hours granted did not match the request for 35 hours per week, the increase was granted in alignment with the task tool. There is no documentation regarding which personal care needs, if any, are not being met by her increased allotment of personal care hours. Therefore, there is insufficient evidence that the requested increase in personal care hours is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Infectious Disease.
Inpatient Hospital.

Diagnosis: Right Arm Abscess (Cellulitis).
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld.

The patient is a previously healthy female who presented to the emergency department (ED) with an abscess on the right arm. The lesion began as a pimple on the right bicep. She was seen by her primary medical doctor (PMD), and she was started on oral antibiotics 2 days prior. A virtual visit was had with the patient's PMD on the day of the presentation, and they recommended ED follow-up. The review of symptoms (ROS) was negative for fevers, vomiting, diarrhea, cough, or congestion. The lesion began to drain serous fluid while the patient was in the ED.

The patient's ED vital signs were a temperature of 98.2 degrees Fahrenheit, a heart rate (HR) of 100 beats per minute (bpm), a respiratory rate (RR) of 22 breaths per minute, a blood pressure (BP) of 92/67 millimeters of mercury (mmHg), and an oxygen (O2) saturation of 100 percent (%) on room air. The examination noted a 3-centimeter (cm) area of erythema and induration with serosanguinous discharge. Laboratory studies showed a white blood cell count (WBC) of 11 with 53% segmented neutrophils (segs), normal electrolytes except for bicarbonate of 19, and was otherwise unremarkable. The patient was placed on intravenous (IV) antibiotics and was admitted to the hospital. The patient's fluid culture grew methicillin-resistant Staphylococcus aureus (MRSA) which was sensitive to clindamycin, Bactrim, and vancomycin.

At issue is whether the inpatient hospital admission was considered medically necessary.
I uphold, in whole, the health plan's determination of medical necessity.

The requested inpatient admission was not medically necessary given the patient's age, condition, lack of systemic symptoms, and improvement (drainage) while in the ED.
This otherwise healthy child presented with cellulitis of the right arm with spontaneous drainage that started in the ED. Additional drainage was aided with instrumentation of the wound. The patient was comfortable, afebrile, and had stable vital signs. There was no inability to tolerate oral medications. Thus, this individual could have been treated in the ED and discharged home to complete an oral medication regimen.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Uterine fibroids 
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned in part.

The patient is a female with a history of symptomatic uterine fibroids. The patient underwent an open abdominal myomectomy with removal of multiple fibroids and an ovarian cystectomy. Blood loss was 100 cubic centimeters (cc).

Post-operatively, she was stable. The foley catheter was removed on post-operative day 2. The progress note states the patient is doing well. The progress note on post-operative day 3 states the patient is doing well enough to discharge home. This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. 

On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. On postoperative day 2, if the patient is passing flatus and tolerating regular diet, she is discharged home.

The standard of care was followed in this case. The admission was medically necessary and should be approved based on Milliman Care Guidelines (MCG) Laparotomy. However, it is unclear why the patient was not discharged on post-operative day 3 as nothing was done in the hospital that day.

Based on the above, the insurer's denial must be overturned in part. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for an inpatient hospital admission is substantiated. However, continuous stay for the last 24 hours of admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This is a young child with a history of a strep throat that was diagnosed 2 weeks prior to the hospitalization. He was treated with Amoxil but when his symptoms did not improve his throat was again tested and found to be positive for group B strep (GBS). He was then started on Augmentin by his pediatrician. He then was noted to have a dry cough and nasal congestion. He could not sleep because of the cough, and he was noted to have increased work of breathing. He had a past history of asthma and his mother gave him albuterol in the home. When the increased work of breathing and cough persisted, his mother brought him to the emergency room (ER) for an evaluation.

In the ER he was noted to be in moderate respiratory distress with increased work of breathing, subcostal and intercostal retractions and wheezing.  On physical exam his pulse oximeter was 93% (percent) and the child had diffuse wheezing upon auscultation of the chest, retractions and prolonged expiration.  He was treated with three treatments with DuoNeb, Decadron, magnesium sulfate and an intravenous (IV) normal saline fluid bolus.  Following treatment, he continued to have wheezing and increased work of breathing. When his wheezing was noted to persist, he was treated with an additional albuterol nebulizer treatment.  The decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for an acute episode of wheezing, and difficulty breathing. When he did not respond to treatment in the ER and he was noted to have persistent wheezing with labored breathing and retractions, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with nebulized treatments with albuterol every 2 hours. He was not stable enough to be safely discharged. 

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

The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Attention-deficit/hyperactivity disorder (ADHD)
Treatment: Desoxyn 5MG (milligrams) - 150 tablets/month
The insurer denied: Desoxyn 5MG (milligrams) - 150 tablets/month
The denial is overturned.

This patient is an adult male with attention-deficit/hyperactivity disorder (ADHD). Denial of Desoxyn (methamphetamine) 5mg (150 tablets/month) is being appealed. The patient has been on 
this medication for 11 years.

The Desoxyn is medically necessary. 

Desoxyn is United States Food and Drug Administration (FDA) approved for treatment of attention-deficit/hyperactivity disorder. The initial dose of 5 milligrams once or twice a day is recommended. Daily dosage may be raised until an optimum clinical response is achieved. The usual effective dose 
is 20 to 25 milligrams daily. This request is for continuation of Desoxyn 5 milligrams (150 tablets/month). This quantity is consistent with 25 milligrams per day, which is consistent with 
standard of care. Therefore, continuation of the requested Desoxyn 5 milligrams (150 tablets/month) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter they stated that the patient presented to the hospital with a fast heart rate. There were no unstable vital signs that did not improve or other findings warranting an inpatient admission. The requested admission is denied based on Milliman Care Guidelines 26th Edition for Supraventricular Arrhythmias. 

This is the case of a patient that presented to the hospital with chest pressure and lightheadedness following an assault.  Past medical history was significant for hypertension and coronary artery disease status post coronary stent placement. On arrival to the hospital, the patient was tachycardic and pulse was 91 and irregular, blood pressure was 154/91.  Physical examination revealed no significant abnormality other than an irregular pulse. 12 lead electrocardiogram (ECG) demonstrated atrial flutter with a ventricular rate of 104. No ST or T ( Sinus Tachycardia) wave abnormalities were noted. Serum blood tests were all within normal limits. The patient was admitted to the hospital for monitoring and treatment. Dual antiplatelet therapy was changed to single antiplatelet therapy plus apixaban. Metoprolol was titrated to control heart rate. The patient was noted to be in atrial fibrillation on telemetry and rates were controlled at 80. The patient was discharged for cardiology follow up in less than 24 hours.

The health plan did act reasonably. This patient presented with symptomatic atrial flutter and was effectively treated with atrioventricular (AV) nodal blocking agents. Following evaluation and additional testing, the patient was deemed to have a controlled heart rate and was released from the hospital. Bellew et. al. studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission (2). This patient had a heart rate of 80 shortly after treatment with beta blocker therapy. In conclusion, this patient could have been managed at a lower level of care, inpatient hospital admission was not medically necessary.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: renal calculi

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 


This is an adult female with a history of renal calculi. The patient presented to the emergency department (ED) with complaints of left flank pain. Imaging revealed an 8 millimeter (mm) obstructing right upper ureteral calculus. The patient was admitted, taken to the operating room (OR) for cystoscopy, Right retrograde, Right stent placement. The patient improved after the procedure. She was ambulatory, voiding, passing flatus, tolerating her diet. She was discharged home with orders for out-patient follow-up. The insurer has denied coverage for the inpatient admission as not medically necessary. They noted the lack of a serious medical condition and stated the patient could have been placed in observation under monitoring. 

The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (26th Ed): 
	
Renal colic + (plus)  Kidney Stones: the patient fails to meet guidelines for acute inpatient admission as no hemodynamic instability, urinary tract infection (UTI), or acute renal failure.
Urologic Surgery or Procedure: the patient meets the discharge parameters within 24 hours past procedure. As per the guidelines, this procedure is performed in the ambulatory surgery setting.

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 the inpatient hospital admission is not substantiated.