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

Diagnosis: Levoscoliosis. 
Treatment: Pain injection (64483 x 1). 
The insurer denied coverage for pain injection (64483 x 1). 
The denial is upheld. 

This patient has levoscoliosis and congenital fusion of L (lumbar) 3-L4 as well as disc herniated discs at L4-L5 and L5-S (sacrum) 1. The patient has symptoms referral to L3. The request is for Transforaminal Epidural Steroid Injection (TFESI) at L3-L4.  However, there is no documentation of recent/adequate conservative therapy. The medical record states that the patient had two weeks of physician directed treatment, including home exercises, physical therapy (PT), and medications with no relief. This is generally not considered an adequate trial. 

Hammerich et al concluded: "Epidural steroid injection plus PT was not superior to ESI alone for reducing disability in individuals with lumbar spinal stenosis (LSS). Significant benefit was found for the addition of PT related to quality-of-life factors of emotional function, emotional well-being, and perception of general health" (1). 

"Among conservative treatment methods aiming to alleviate pain and improve physical function in patients with lumbar disc herniation, many patients choose physical therapy and alternative therapy solely or in combination with other therapeutics mentioned above" (2). 

Up to Date regarding epidural injections notes that "Epidural injection - Epidural glucocorticoid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain. However, understanding efficacy is difficult due to inconsistent results as well as heterogeneous populations and interventions in randomized trials. In 2014, the US Food and Drug Administration (FDA) issued a drug safety communication about epidural injection of glucocorticoids, noting the potential for rare but serious adverse effects (loss of vision, stroke, paralysis, and death) and that effectiveness has not been established. 

The best evidence for benefit comes from trials for patients with radiculopathy due to a herniated disc, which demonstrate short-term, but not long-term, benefit" (3). 

With regard to exercise therapy, Up to Date notes that "Prescribe exercise - We advise exercise for all patients with subacute and chronic low back pain (LBP). LBP is associated with decreased strength, endurance, lumbar muscle atrophy, and fatigability. 

In several systematic reviews, exercise modestly improved pain and function in patients with subacute and chronic LBP. In addition, patients with chronic LBP who regularly participate in moderate to vigorous leisure-time activities have less pain and better function compared with those who are less physically active" (4). 

Thus,  it is medically reasonable and necessary that a trial of conservative therapy be attempted before interventions. 

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 pain injection (64483 x 1) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal/Back Pain
Surgical Services/Facet joint injections
The health plan denied the requested Facet joint injections as not medically necessary. The health plan's determination is overturned.

The patient is a male with a history of low back pain. A note with his physician indicates that the patient has had back pain for 4 years. A recent magnetic resonance imaging (MRI) of the lumbar spine indicates that they had significant facet arthropathy at the (lumbar-sacral) L5-S1 level and performed therapy 4 years ago for similar complaints. On the notes it was documented that they recently completed physical therapy which made the pain worse. They were also treated with Meloxicam and Tylenol prior to the visit. On exam there was limited range of motion in the spine especially with lumbar extension. His treating physician recommended bilateral (lumbar) L3 to L5 medial branch blocks.
At issue is the medical necessity for the requested health service/treatment of facet joint injections.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The requested health service/treatment of Facet joint injections are medically necessary for this patient
Facet joint injections or medial branch blocks can be considered for patients with a history of axial or non-radicular low back (lumbosacral), mid-back (thoracic) or neck (cervical) pain, unless stenosis is caused by synovial cyst
-Lack of evidence for discogenic or sacroiliac joint pain as the main pain generators.
-Lack of disc herniation or evidence of radiculitis as the main pain generators (unless stenosis is caused by synovial cyst).
-Block will not be performed at same level(s) as previous surgical fusion.
-Pain causing functional disability or average pain levels of >= 6 on a scale of 0 to 10.
-Duration of pain of at least 3 months.
-Failure to respond to conservative non-operative therapy for a minimum of 6 weeks in the 6 months prior to facet blocks, OR documentation of active engagement in other forms of active conservative non-operative therapy if the patient had prior spinal injections, unless the medical reason this treatment cannot be done is clearly documented. Also, injections should be performed with fluoroscopic or computed tomography (CT) guidance.
No more than three spinal levels (unilateral or bilateral) are to be treated at the same session.
The original denial by the health plan was based on no documentation of recent therapy and no documentation of treatment with medication. However, as described above, these treatment modalities were documented in the notes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD), with fever, cough and shortness of breath
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male active smoker, with chronic obstructive pulmonary disease (COPD), with fever, cough and shortness of breath. The patient was found to be hypoxic and was placed on oxygen in the emergency room. The patient was found to have viral infection in the emergency room (ER). The patient was treated for chronic obstructive pulmonary disease exacerbation and was admitted to acute inpatient hospital level of care. The hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was not medically necessary.

The patient was admitted to the hospital for chronic obstructive pulmonary disease exacerbation due to viral infection. The patient briefly needed oxygen in the emergency room. At the time of admission, the patient was hemodynamically stable. The patient was not in respiratory distress. The patient's saturations were above 90 percent on minimal oxygen. The patient was tolerating diet and was ambulating. The patient did not receive any treatment that could not have been provided at a lower level of care. The proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID 19

Treatment: Vitamin D testing

The insurer denied coverage for Vitamin D testing

The denial is upheld

 
According to documentation submitted, patient is an adult with past medical history significant for recovering from COVID-19 infection. 

At issue is the denial of coverage for vitamin D testing as not medically necessary. Provider appeal letter states that vitamin D levels are needed for evaluation of fatigue, and "long COVID which is known to inhibit hyperinflammatory reactions and helps with accelerating healing process." 

As noted in the provider's appeal letter, there are publications showing non-skeletal functions of vitamin D, especially its inhibitory effects on the production of pro-inflammatory cytokines including interleukin (IL)-6, and the association of its deficiency with many immune-related diseases including COVID-19.

Current data, however are mostly from retrospective studies, have not established a definite cause-effect relationship between vitamin D levels and its suggested anti-COVID-19 efficacy; further investigation, such as well-controlled clinical trials, may be needed before vitamin D could be considered in clinical management of COVID-19, including chronic or long COVID, and fatigue symptoms that may be associated with infection. Currently, there is no clear evidence that vitamin D supplementation reduces the risk or severity of COVID-19. Subsequent large trials have not shown a benefit of vitamin D supplementation on COVID-19 outcomes. Therefore, routine screening of vitamin D is currently not recommended since, clinical interpretation of this testing result is often complicated and does not change clinical management.

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 vitamin D testing is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, nausea and vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

Patient is an adult with a benign past medical history who presented to the emergency department for complaints of fever, nausea, and vomiting. She attributed the nausea and vomiting secondary to recently prescribed oral antibiotics (Macrobid).

Vitals on presentation included: Maximum temperature 104.5 degrees Fahrenheit, Blood Pressure 118/76, Pulse 112 beats per minute, Respiratory Rate 18 breathes per minute, oxygen saturation  97% (percent) on Room Air. Laboratory values were notable for the following: white blood cell (WBC) count 5.1, hemoglobin (Hgb) 11.8, hematocrit (Hct) 39.7, creatinine 0.93, glucose 124, lactate 0.98, procalcitonin 0.26.

Patient was admitted for evaluation of fever. Chest X-ray (CXR) was negative. Computed tomography (CT) scan of abdomen/pelvis did not show any abnormalities. Patient was empirically started on intravenous antibiotics (vancomycin and Zosyn). Blood cultures remained negative. Urine culture grew Enterococcus faecalis. Patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management with oral antibiotics (Augmentin). 
     
According to medical records, patient presented with complaints of fever; otherwise, she remained hemodynamically stable. Laboratory results were unremarkable including a normal White blood cell (WBC) count, lactate, and procalcitonin. Imaging studies were all negative. Patient had no evidence of a disseminated infection and no intervention requiring acute inpatient care. Based on above findings, patient met criteria for observation level of care.
 
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.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department (ED) complaining of chest pain and dyspnea. He had been seen earlier that day complaining of generalized weakness and had been discharged. He had also been hospitalized and discharged earlier for complaints of palpitations.

Based on the documentation provided an inpatient hospital admission was not medically necessary.
This man presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. He did not require acute intervention, intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Mid Back Pain (spondylosis without myelopathy or radiculopathy; thoracic region)
Treatment: Injections (64491, 64490)
The insurer denied: Injections (64491, 64490)
The denial is overturned.

The patient is an adult male. He was noted to have severe chronic axial mid back pain. The patient failed nonsurgical management. His exam reveals T(thoracic) 10-12 tenderness to palpation of the facets. The recommendation was for thoracic medial branch block (MBB).

The requested Injections (64491, 64490) are medically necessary.

This patient has clear facet-mediated pathology, and the procedure is the first step to diagnose and treat the patient's symptoms. If a medial branch block were to improve the patient's symptoms x(times) 2, then he would be a candidate for radiofrequency ablation (RFA), which is a more long-lasting procedure. This is well-accepted by the spine community and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes.
Treatment: Inpatient hospital admission.

The insurer denied the inpatient hospital admission.  The denial is overturned.

The patient is a teenage female with type 2 diabetes mellitus and obesity. She was hospitalized within the last year for worsening of her type 2 diabetes mellitus. She also had nonalcoholic steatohepatitis (NASH) based on elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and socially was living in a homeless shelter. She had previously been started on treatment with metformin for type 2 diabetes mellitus last year and had some trouble being adherent to the metformin medication due to gastrointestinal side effects. Her hemoglobin A1c (glycated hemoglobin) before the hospitalization increased to 10.7% (percent) in clinic with a blood glucose of 195 mg/dL (milligrams per deciliter), and so she was admitted to the hospital for insulin initiation.

During her hospitalization, the patient and her family received diabetes education, including teaching on how to safely give insulin. The patient's glucose levels stabilized, and she was treated with metformin and basal (Lantus) and bolus (Humalog) insulin. The hospitalization was denied coverage by the health plan because besides hyperglycemia, the patient she did not meet any of the other criteria required by the health plan, such as altered mental status, significant electrolyte abnormalities, etc ("and the rest"). The denial is being appealed.

The inpatient hospital admission was medically necessary.

While the patient did not evidence altered mental status or significant electrolyte abnormalities, the treatment and hospitalization were medically necessary.

The emergency department (ED) and endocrinology attending felt the admission was medically necessary. The patient's hemoglobin A1c level was 10.7%. It is indicated in the American Diabetes Association guidelines to recommend insulin initiation with hemoglobin A1c above 8.5%. As noted by the ED attending, it was not safe to discharge the patient home, and she required admission for insulin initiation. The patient lived in a homeless shelter, and she could not be started on insulin without intensive education. It was not safe for the family to initiate this insulin therapy in their home environment, and it was not safe to discharge them home without insulin. They were seen late in the evening, and the clinic did not have the ability to perform the education needed in the outpatient setting over the following days.

Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
treatment: Consumer Directed Personal Assistance Services (CDPAS) 34 hours/week
The insurer denied the CDPAS 34 hours/week.
The health plan's determination is upheld. 

This is a case review for a male with medical history notable for asthma. The patient and his care team requested Consumer Directed Personal Assistance Services (CDPAS) 34 hours/week.

The patient's nurse practitioner provided a letter for this appeal. The letter states that the patient has a diagnosis of sarcoidosis, chronic obstructive pulmonary disease (COPD), anxiety, depression, hypertension, and asthma. The letter states that the patient's current hours are insufficient to meet the needs of his medical conditions and they requested an increase in his home health hours. Further detail regarding which personal care needs were not being met was not provided.

The requested CDPAS 34 hours/week was not medically necessary for this patient.

The patient's personal care needs mostly revolve around his instrumental activities of daily living. The task tool recommended hours are typically sufficient to complete these needs. He is receiving the number of hours recommended by the task tool. He is independent with his activities of daily living. There is no documentation regarding which personal care needs, if any, are not being met with his current allotment of 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: Overturned

Diagnosis: Breast cancer

Treatment: CPT 99214 x (times) 2 established patient office or other outpatient visit, 30-39 minutes, 19350 Reconstruction of nipple or area around nipple, 19357 Reconstruction of breast using tissue expander, and 15777 Implantation of biologic implant to soft tissue

The insurer denied coverage for CPT 99214 x 2 established patient office or other outpatient visit, 30-39 minutes, 19350 Reconstruction of nipple or area around nipple, 19357 Reconstruction of breast using tissue expander, and 15777 Implantation of biologic implant to soft tissue.

The denial is overturned.

 
The patient has breast cancer and requires breast reconstruction following mastectomy. The plan is for nipple reconstruction and breast implant expander placement. The request is for the reconstruction services to be completed by an out-of-network provider. The insurer has denied out-of-network surgical services stating the services are available within the network  The insurer has also denied the medical necessity of the requested services.

The request was made to determine the medical necessity of the requested procedure AND if the services were approved or denied for out of network benefits.  The evaluation for medical necessity was determined first followed by the decision to allow out of network services.

The patient has breast cancer and requires breast reconstruction following mastectomy. The plan is for nipple reconstruction and breast implant expander placement. The records do not include any documentation from the plastic surgeon. However, breast reconstruction is medically necessary. The Women's Health and Cancer Rights Act of 1998 (WHCRA) mandates coverage for all stages of breast reconstruction following mastectomy. "The Women's Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy."

The health plan in-network physician does not have the appropriate training and experience/expertise to meet the healthcare needs of the patient. The out-of-network physician is likely to produce a more clinically beneficial outcome for the patient.

Based on the above, the insurer's denial is 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 and utilization of out-of network services for CPT 99214 x 2 established patient office or other outpatient visit, 30-39 minutes, 19350 Reconstruction of nipple or area around nipple, 19357 Reconstruction of breast using tissue expander, and 15777 Implantation of biologic implant to soft tissue is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic constipation.

Treatment: Motegrity 2 milligram (mg) tablet.

The insurer denied coverage for Motegrity 2 milligram (mg) tablet.

The denial is overturned.

The insurer has denied coverage for Motegrity 2 milligram (mg) tablet. In a Final Adverse Determination letter, they stated that coverage can be provided for when documentation has confirmed that the patient has tried and failed at least three preferred formulary alternatives. Formulary alternatives are Lubiprostone, Linzess, and Trulance. 

The patient's Gastroenterologist is appealing. It is stated that the patient has a history of ulcerative colitis, eating disorder, chronic slow motility, and chronic constipation. The patient has tried and failed senna, MiraLAX, Colace, and Linzess. Linzess maybe used in addition to Motegrity. The patient is not a candidate for Trulance or Lubiprostone. The patient has been doing well on Motegrity.

The patient has a history of slow intestinal motility resulting in chronic constipation. The patient has tried and failed in the past MiraLAX, senna, and Linzess. The patient's physician feels that they would not benefit from Trulance or Amitiza since they have similar mechanisms of action to the Linzess. The physician has also included references from several articles in the medical literature that support the use of prucalopride for functional constipation and gastroparesis. 

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacologic therapy. Both Linzess and Trulance are Guanylate cyclase-C receptor agonists that are beneficial for chronic constipation. Prucalopride is a selective serotonin-4 receptor agonist which acts as a gastrointestinal (GI) prokinetic agent to stimulate peristalsis and increase bowel motility. It has been shown to be superior to placebo in several trials that were followed up to 24 months. 

This patient has a motility disorder that has resulted in chronic constipation. The patient has failed treatment with Linzess. There is a concern raised by the physician that giving Trulance would also be ineffective since it has the same mechanism of action as Linzess. Treatment with Motegrity has been shown to stimulate peristalsis and would likely be more effective than the other formulary drugs for constipation due to the motility disorder. The formulary drugs are not likely to cause an adverse reaction but likely will not be effective. Due to the mechanism of action of Motegrity it is likely to be more effective. The denial of Motegrity is reversed.

The carrier's denial of a request for a Formulary Exception for Motegrity 2 milligram (mg) tablet is reversed.