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

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.  
The denial has been upheld.
The proposed treatment was not medically necessary.

The patient is a male.  The patient had a past medical history of hypertension, hyperlipidemia, cerebral vascular accident (CVA), and tobacco use.  He presented to the emergency department for evaluation of chest pain, generalized weakness, dizziness, and hypotension.  On arrival to the emergency department, he was afebrile, blood pressure was 134/87, and oxygen saturation (SPO2) was 98 percent on room air.  The patient's initial labs were notable for a white blood cell (WBC) count of 4.1, hemoglobin of 11.7, and troponin which was within normal limits.  The electrocardiogram (EKG) showed normal sinus rhythm without any acute ischemic changes.  

The patient was admitted to the inpatient unit and was evaluated by cardiology.  Coronary computed tomography angiogram (CTA) did not demonstrate any evidence of occlusive coronary artery disease.  The patient was initiated on guideline directed medical therapy for coronary artery disease and was discharged with outpatient follow-up.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ Mal perfusion.  There was no evidence of acute coronary syndrome given that troponins were within normal limits.  There was no evidence of unstable angina.  Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.  Observation level of care would have been appropriate in this case.       

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

Due to the reasons stated above, there is insufficient clinical data to support medical necessity for admission to inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Syncope
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a female who presented with right hand numbness with right hand and right leg weakness. She also reported passing out while at a nail salon and she noted these symptoms upon waking. Upon arrival at the emergency room, she was no longer with weakness but still noted mild numbness to her right upper extremity. The patient also complained of right sided neck pain and some blurry vision. There was no facial droop or slurred speech. Upon examination she was not in any acute distress. She had mild to moderate sensory loss on examination. 
A magnetic resonance imaging (MRI) of the cervical spine did not show spinal stenosis or foraminal narrowing. She was discharged in stable condition with outpatient follow up with neurology and an electroencephalogram (EEG).

The inpatient hospital admission was medically necessary. The patient has a syncopal event associated with an acute neurologic change. Her laboratory studies were unremarkable. A computed tomography (CT) scan of the head did not show any acute intracranial pathology. A computed tomography angiography (CTA) of the carotids was grossly unremarkable. A chest x-ray did not show any acute cardiopulmonary findings. Neurology was consulted and she was admitted to the inpatient stroke unit. She was not given thrombolytics as symptoms were considered to be mild. She was started on Aspirin and a brain MRI was ordered. The brain MRI did not show any intracranial pathology.
She was evaluated by neurology in the emergency room and given her symptoms it was reasonable to admit her to the stroke unit with the expectation that she would require a greater than two midnight hospital stay. She required frequent neurologic monitoring and urgent imaging to rule out a progressive cerebrovascular event. This could only be done in an inpatient setting.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome. 
Treatment: Outpatient services (37241 x 1). 
The insurer denied coverage for outpatient services (37241 x 1). 
The denial is upheld. 

The patient has a chief complaint of pelvic pain. She was reportedly diagnosed with pelvic congestion syndrome. Ovarian vein studies revealed ovarian veins with significant reflux. The treating physician requested coverage for outpatient surgery (37241 x 1). 

Pelvic congestion syndrome (PCS), also known as chronic pelvic pain syndrome or pelvic venous incompetence, is caused by utero-ovarian varices. PCS is defined by engorged pelvic veins of more than 10 millimeters (mm) diameter on selective transuterine venography in multiparous, premenopausal women with a history of chronic, noncyclic pelvic pain for more than six months. 

Two randomized clinical trials suggest that medical treatment with gonadotropin-releasing hormone agonists or synthetic progestins effectively decrease pain associated with pelvic congestion. 

Note that the procedure may have the following complications: 

-	Those related to drug administration, e.g., narcosis, sedation or rarely hypersensitivity, for example to iodinated contrast (reported in less than 1 % of patients with non-ionic contrast). 
-	Venous puncture related, e.g., hematoma, pneumothorax (for venous catheterization via a neck vein). 
-	Embolization of non-target vessels, i.e., coil misplacement, e.g., left ovarian vein involving left renal vein, obturator or circumflex coil protruding into left external iliac or common femoral vein. Caution is advised with liquid embolic agents as communications have been shown to exist between the ovarian veins and paravertebral veins and specifically between the left ovarian vein and splenic, ureteric and inferior mesenteric veins. 

-	Stroke related to paradoxical emboli from coil migration or uncontrolled foam. 

-	Delayed complications can include: Enlarging pneumothorax, initially asymptomatic  and Coil migration (for example: pulmonary embolization of coils). 

The procedure 37241 x 1, closing of blood vessels in the pelvis is not considered more beneficial for this patient's diagnosis. 

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

The outpatient procedure 37241 x 1, does not need approval from the appropriate regulatory bodies for this diagnosis. 

Due to lack of scientific evidence of health improvement, it is unknown if this patient is a good candidate for outpatient procedure 37241. 

The outpatient procedure 37241 is not the best available treatment for this patient at this time. 

The adverse risks are increased over standard treatment/services. 

In summary, the denial of outpatient services (37241 x 1) 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 substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome. 
Treatment: Outpatient services (37241 x 1). 
The insurer denied coverage for outpatient services (37241 x 1). 
The denial is overturned. 

The patient has a diagnosis of pelvic congestion syndrome with symptomatic varices arising from a refluxing ovarian vein. The pathology of the refluxing ovarian vein has been documented by venography. The treating physician requests authorization to treat this with an established modality of care (ovarian vein coil embolization). Denial of authorization is under review. 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes. 

Current literature, and literature over the past decade, as well as standards of practice should result in approval of this procedure. 

According to multi-society evidence-based guidelines: 

"We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together." (Gloviczki, P., et al. 2011). 

The insurer attempts to define the procedure as investigational based upon the absence of randomized controlled studies. However, randomized controlled studies regarding an invasive procedure of this nature are notoriously difficult and expensive to perform, and it is unlikely that these will be available in the foreseeable future. Pelvic and gonadal vein embolization is well documented to be safe and effective and is commonly practiced as the "standard of care" in these settings. 

Outpatient services (37241 x 1) have final approval from the appropriate regulatory bodies for this diagnosis. Regulatory approval for this procedure has been present for decades.  

The records show no reason that the patient is not a good candidate for treatment. 

The requested treatment is the current standard of care for the patient. 

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

The requested service is the standard treatment/procedure for this patient. It is more likely to be beneficial than is denial of the standard treatment and there is no other good alternatives for the patient. 

In summary, the denial of outpatient services (37241 x 1) and coverage for the requested treatment 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: Formulary Exception
Decision: Upheld

Diagnosis:  Gastroesophageal reflux disease (GERD)
Treatment: Sucralfate Suspension
The insurer denied: Sucralfate Suspension
The denial is upheld.

This is an adult male patient with gastroesophageal reflux disease (GERD) who has failed omeprazole, rabeprazole, and famotidine. His esophagogastroduodenoscopy (EGD) was normal. The request is for Carafate suspension.

The health plan should not cover the proposed treatment.

The formulary drug has not been ineffective. The non-formulary drug would not have greater efficacy compared to the formulary drug. The formulary drug would not have a greater number of adverse effects compared to the non-formulary drug. Four randomized, placebo-controlled investigations with variable doses (1 gram twice a day [BID] to 1 gram four times a day [QID]) and durations of treatment (6, 8, and 12 weeks) showed that Sucralfate provided some benefit over placebo in improving symptoms and healing erosive esophagitis, even though statistical significance was not achieved in two of the studies (Surdea-Blaga T et al). A multicenter trial demonstrated that Sucralfate was better than placebo in healing endoscopic lesions (Williams RM et al). A meta-analysis also confirmed the superiority of Sucralfate over placebo as maintenance therapy of gastroesophageal reflux disease (GERD) (Donnellan C, et al).
The literature does not support the efficacy of Sucralfate suspension over Sucralfate tablet.
Appeal type: Medical necessity
Decision: Overturned


 
Diagnosis: heart disease, stroke, diabetes and renal failure

Treatment: personal care aide (PCA) services 84 hours per week

The insurer denied coverage for personal care aide (PCA) services 84 hours per week

The denial is overturned

The patient is an elderly female with multiple medical problems including heart disease, stroke, diabetes and renal failure.  She lives alone in a private residence.  She was receiving personal care aide (PCA) services 56 hours/week and requested 84 PCA service hours/week.  The insurer approved 63 PCA hours/week.  Under review are the denied 21 PCA service hours/week.   
 
According to the Uniform Assessment System (UAS) report, the patient's cognition is minimally impaired.  She is self-directing, able to make her needs known, has the capacity to properly activate a Personal Emergency Response System (PERS) unit and can call Emergency Medical Services (EMS) if necessary.  However, she is reportedly totally dependent requiring maximal assistance for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet use.  Extensive assistance is reportedly needed for upper body dressing, locomotion, toilet transfer and ambulation.  Limited assistance is reportedly needed for personal hygiene and eating.  Supervision is reportedly needed for bed mobility.  The patient is frequently incontinent of bladder and continent of bowel.  

There has been a reported decline in her ability to perform Activities of Daily Living (ADL) tasks and she fell during the prior 90 days.  This physician is also persuaded by the letters from the treating physicians who described her multiple co-morbidities and associated impairments. Her medical condition and physical limitations are at the level or unpredictable as to require the requested PCA services 84 hours/week.  Based on the records reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCA services to 12 hours/day, 7 days/week, and total 84 hours/week.  

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 personal care aide (PCA) services 84 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with a past medical history  that includes coronary heart disease, diabetes, cerebrovascular accident (CVA), hemiplegia, hypertension, and hyperlipidemia. Per the telephonic Uniform Assessment for New York (UAS-NY) the patient lives alone. The patient reported having a few falls at home. The patient is alert and oriented (A+O) times 3. The patient can activate a personal emergency response system (PERS). The patient requires maximal assistance with meal preparation, housework, stairs, shopping, transportation, bathing, dressing lower body, walking, and toileting. The patient requires extensive assistance with managing medications, personal hygiene, and dressing upper body. The patient's activities of daily living (ADL) status has declined within the past 90 days.. The patient had two or more falls within the last 90 days. The patient lives alone. There were no hospitalizations within the last 90 days. 

Reckrey, J. M., Tsui, E. K., Morrison, R. S., Geduldig, E. T., Stone, R. I., Ornstein, K. A., & Federman, A. D. (2019), "Older adults prefer to remain living at home even with the substantial functional impairment that is common in the last years of life.(1,2) This fact, in combination with growing evidence of the cost effectiveness of community-based long-term care, is driving interest in shifting the locus of long-term care from institutions to the community.(3-6) Paid caregivers (e.g. home health aides, personal care attendants, and other direct care workers) will increasingly be needed to provide the hands-on care that supports this shift.(7) The large and growing workforce of paid caregivers spends hours each day with patients with functional impairment and witnesses their chronic health needs, changes in health status, and psychosocial stressors. As a result, paid caregivers have the potential to serve as valuable members of patients' multidisciplinary health care team and influence health outcomes."

"The activities of daily living (ADLs) is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. The term activities of daily living was first coined by Sidney Katz in 1950. ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs." (Edemekong, P. F. et al. 2022).



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 personal care services, 12 hours a day, 7 days a week for a total of 84 hours a week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke with dense left hemiplegia and aphasia

Treatment: Increase in Personal Care Aide (PCA) services to Level 2: 12 hours per day - 7 days per week (Split-Shift) for a total of 168 hours per week

The insurer denied coverage for increase in Personal Care Aide (PCA) services to Level 2: 12 hours per day - 7 days per week (Split-Shift) for a total of 168 hours per week.
The denial is overturned.

According to the medical records, the member is an adult female who is bed-bound from a severe stroke with dense left hemiplegia and aphasia. She also has heart failure, hyperlipidemia, hypertension, and osteoarthritis. She is incontinent of bowel and bladder and needs maximum assistance for bed mobility. She is at high risk for pressure ulcers and must be turned every two (2) hours for skin protection. Her incontinence is frequent, and because she is incontinent of urine and stool, mechanical measures for keeping her dry at night (such as a PureWick) are contraindicated. It has been documented that the member's incontinence requires change of pads roughly every 2 hours. Even if she were a candidate for a supra-pubic catheter, a high fiber diet to reduce bowel incontinence frequency and every 2 hour turns (by a caregiver) would still be medically necessary.

"Conclusions: Incontinent patients had higher Braden Scale scores and higher overall and FAPU prevalence. Incontinence was associated with an increased risk for all pressure ulcers, but especially full-thickness injuries." (Lachenbruch, C. et al.).

"The prevention and treatment of pressure ulcers are highly relevant to wound care professionals. These patients require prolonged course of treatment to fully heal their wounds. The biomedical burden is tremendous as noted above and healthcare expenditures on this problem are only rising. Penalties now imposed for hospital-acquired pressure ulcers mean we need greater knowledge about causation and prevention." (Boyko, T. V. et al.).

 Landers, S., et al., "Medicare skilled home health" care or "home health care" refers to services offered by Medicare-certified home health agencies under the Medicare home health benefit. By contrast, "home-based care" refers to a wide array of different types of care provided in the home by a wide range of parties. The continuum of different types of home-based care delivered in the home varies in terms of different dimensions, including acuity, type of care provided, and degree of physician involvement. Home-based care includes both formal and informal personal care services, Medicare skilled home health, physician house calls, and even "hospital-at-home" services."     
                                                     
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 an increase in Personal Care Aide (PCA) services to Level 2: 12 hours per day - 7 days per week (Split-Shift) for a total of 168 hours per week is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic back pain
Treatment: Procedure codes 64628 and 64629 (intraosseous basivertebral nerve ablation) (procedure to treat your back)
The insurer denied coverage for procedure codes 64628 and 64629 (intraosseous basivertebral nerve ablation) (procedure to treat your back)
The denial is upheld

This patient has chronic low back pain. He has tried Heat/ Ice, physical therapy (PT), transcutaneous electrical nerve stimulation (TENS), Epidural Steroid Injection (ESI), and microdiscectomy.  His magnetic resonance imaging (MRI) shows Modic changes at lumbar  (L)3-L4 and L4-L5.  The request is for radiofrequency ablation (RFA) of the Basivertebral nerves (BVN) at L3, L4 and L5.	

The publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates.  There are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:

1. Industry funding is a potential source of study bias for the available data reviewed.
2. Limited number of studies.
3. Short-term follow up for the majority of studied patients.
4. Unknown effect on the primary degenerative process

Urits et al (5) also commented on the need for more research on this promising technique:  "reproducible large randomized controlled trials (RCTs) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RFA in the management of chronic low back pain (cLBP) and improve the quality of life of cLBP patients in the near future."

In summary, the denial of procedure codes 64628 and 64629 (intraosseous basivertebral nerve ablation) (procedure to treat your back) and coverage for the requested service/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 substantially increased over standard treatments.