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

Diagnosis: Ischemic systolic congestive heart failure
Treatment: Ambulatory surgery; outpatient procedure (33249 x1); placement of a device that helps fix the electrical system in the heart (implantable cardioverter defibrillator)
The insurer denied coverage for ambulatory surgery; outpatient procedure (33249 x1); placement of a device that helps fix the electrical system in the heart (implantable cardioverter defibrillator)
The denial is overturned.

This is an adult with a history of diabetes mellitus, peripheral vascular disease, myocardial infarction and ischemic systolic congestive heart failure that was referred for primary prevention implantable cardiac defibrillator implantation with cardiac resynchronization pacing. The patient's exercise tolerance was consistent with New York Heart Association Class II functional status. On examination, the patient's vital signs were stable, and the patient was euvolemic. A 12-lead electrocardiogram demonstrated normal sinus rhythm with left bundle branch block with a QRS (combination of the Q wave, R wave and S wave) complex duration of 177 milliseconds (msec). Perfusion testing demonstrated a left ventricular ejection fraction (LVEF) of 11 percent (%). The patient was treated with guideline-directed medical therapy including Entresto, carvedilol, and Farxiga.  

Current guidelines support placing an implantable cardioverter defibrillator (ICD) in patients with ischemic cardiomyopathy and left ventricular ejection fraction (LVEF) less than 30%, regardless of medical therapy duration. 

This patient has a high risk of sudden cardiac death. The net risk reduction for total mortality in patients with ischemic heart disease that are treated with ICD therapy is 20-30%. Records demonstrate a severely depressed left ventricular ejection fraction. This patient has a class I indication for primary prevention implantable cardiac defibrillator placement. 

Ambulatory surgery; outpatient procedure (33249 x1); placement of a device that helps fix the electrical system in the heart (implantable cardioverter defibrillator) is considered medically necessary for this patient.

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 ambulatory surgery; outpatient procedure (33249 x1); placement of a device that helps fix the electrical system in the heart (implantable cardioverter defibrillator) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

This is a male patient for whom an inpatient hospitalization is under review. There was a history of hyperlipidemia and the patient presented with several months of worsening dyspnea and chest pain with minimal exertion. Myocardial perfusion imaging (MPI) stress testing demonstrated a large area of anterior reversible ischemia with an ejection fraction (EF) of 60-65 percent (%). He presented electively for cardiac catheterization. He underwent a successful and uncomplicated percutaneous intervention. The creatinine was 0.81. He remained stable and was discharged. At issue is the medical necessity of an inpatient stay. 

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abdominal wound
Treatment: Computed Tomography (CT) of Abdomen and Pelvis 
The insurer denied Computed Tomography (CT) of Abdomen and Pelvis. 
The health plan's determination is overturned. 

The patient is a woman with a nonhealing abdominal wound. She has a history of remote hysterectomy, cholecystectomy, and umbilical hernia repair with mesh. The patient underwent operative debridement of an abdominal wound. This operative dictation describes that the patient has had multiple infections and multiple revisions of the abdominal wall.

The Computed Tomography (CT) of Abdomen and Pelvis is medically necessary for this patient.
The records submitted for review include the multidisciplinary evaluation of a patient with a complex complication dating back years. She has a refractory abdominal wound that persists despite multiple attempts to treat this with surgical debridement and antibiotics. It was the opinion of the plastic surgeon, the general surgeon and the wound care clinic that she be reassessed with abdominal and pelvic CT scan to assess for an occult abdominal wall abscess.
Per the submitted clinical material this patient has persistent abdominal pain and intermittent drainage from an abdominal incision. As described above, she had a history of prior mesh hernia repair 10+ years ago. Imaging with CT scan is an appropriate diagnostic tool to evaluate this patient with refractory abdominal pain and a poorly healing abdominal wound.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Thermal destruction of intraosseous basivertebral 
nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral (64628)
The insurer denied: Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral (64628)
The denial is overturned.

The patient is an adult male. 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 vertebral genic pain identified by Modic changes on magnetic resonance imaging (MRI). The patient has pain and failed treatment for greater than six months. Prior treatments include chiropractic care, activity modification, home exercises, epidural steroid injections and medial branch blocks, sacroiliac (SI) joint injection and radiofrequency ablation in addition to physical therapy.

The health plan should cover the requested health service.

Based on the documentation provided, the requested Intracept procedure is recommended in this case. It was noted that the patient had tried and failed prior treatments with continued symptoms. The patient has pain and failed treatment for greater than six months. Prior treatments include chiropractic care, activity modification, home exercises, epidural steroid injections and medial branch blocks, sacroiliac (SI) joint injection, and radiofrequency ablation in addition to physical therapy. Imaging does support the requested procedure. The patient has a positive Modic changes on MRI (magnetic resonance imaging). The requested procedure is FDA (United States Food and Drug Administration) approved for such findings and diagnosis.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Thermal destruction of intraosseous basivertebral 
nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral (64628)
The insurer denied: Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral (64628)
The denial is upheld.

The patient is an adult male with low back pain radiating into the left buttocks and posterior thigh that began over six months ago. Past treatments include chiropractor, massage, physical therapy, activity modification, home exercise, lumbar epidural steroid injections, medial branch blocks, radiofrequency ablations, sacroiliac joint injections, and diclofenac. The patient's pain is a 6/10. Magnetic resonance level (MRI) of the lumbar spine shows bulging discs and degenerative changes at multiple levels with new mild canal stenosis at L (lumbar) 2-3. Degenerative changes at L2-3 are significantly increased from prior MRI (magnetic resonance imaging). There are prominent Modic type 1 and 2 changes at L2-3 with Schmorl's nodes as well as mild Modic type 1 changes at L3-5 that are new and mild chronic anterior wedging at L1.
The request for L2-3 Intracept 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Thermal destruction of intraosseous basivertebral 
nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral (64628)
The insurer denied: Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral (64628)
The denial is overturned.

The patient is an adult male who has 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, epidural steroid injections, facet injections/medial branch blocks (MBBs) and radiofrequency ablation (RFA), home exercises, and chiropractic care. The patient has failed multiple medications. Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not reveal any neurological injury.

The health plan should cover the requested health service.

The requested Intracept procedure is medically appropriate. The patient is an adult male who has 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, epidural steroid injections, facet injections/medial branch blocks (MBBs) and radiofrequency ablation (RFA), home exercises, and chiropractic care. The patient has failed multiple medications. Magnetic resonance imaging (MRI) shows Modic changes. 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 is typically use in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. This patient has failed or attempted all conventional treatments for axial low back pain. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. Alternatives such as spinal fusion do not show good results for axial low back pain without instability and is of greater risk. Given that conservative options have been exhausted, the requested Intracept procedure is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: peritonsillar abscess
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with no past medical history who presented to the emergency department with worsening sore throat and difficulty swallowing, symptoms that had started 2 days before presentation. Having tested positive for streptococcus at urgent care earlier in the day, the patient was concerned about a peritonsillar abscess, prompting Emergency Medical Services (EMS) to bring her to the emergency department (ED).

The inpatient hospital admission was not medically necessary. The patient presented with pharyngitis and peritonsillar abscesses, however, she had no signs of hemodynamic instability, airway obstruction, impending obstruction, or extension of infection into deep tissues of the neck or superior mediastinum. There was no need for surgical intervention or thrombophlebitis of the internal jugular vein. Overall, the patient responded to treatment with antibiotics and corticosteroids very fast and was discharged home with a prescription for oral antibiotics the day after admission.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain and dyspnea

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient is an adult with a history of hypertension, hyperlipidemia, coronary artery disease and multiple PCI's (percutaneous coronary interventions) who presented to the emergency department with chest pain and dyspnea for an elective intervention. The patient had  a PCI of the right coronary artery. The patient continued to have chest pain. The patient was referred for cardiac catheterization which was performed. It showed in-stent restenosis. The patient underwent PCI including implanting a second drug-eluting stent.

The patient was observed overnight uneventfully. The patient was discharged the following day.

The patient had an elective coronary intervention. It was reasonable to observe the patient for several hours after intervention, but this could have been performed on observation status. A full in-patient 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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism

Treatment: current procedural terminology (CPT) code 81291 - 5, 10 methylenetetrahydrofolate reductase (MTHFR), gene analysis, common variants (e.g. 677T, 1298C)

The insurer denied coverage for current procedural terminology (CPT) code 81291 - 5, 10 methylenetetrahydrofolate reductase (MTHFR), gene analysis, common variants (e.g. 677T, 1298C)

The denial is upheld.
 
The patient is an adult, who had been diagnosed to have Pulmonary Embolism. The patient was treated with Eliquis for same. The patient's doctor recommended testing for the methylenetetrahydrofolate reductase (MTHFR) Gene.

Based on review of current literature and society guidelines there is no indication that this testing was indicated or that it improves health outcomes or management of this condition in any way.

All patients with established Venous thromboembolism (VTE) should undergo a thorough History and Physical combined with a review of diagnostic imaging studies and routine laboratory testing. Most experts agree that routine evaluation for hypercoagulable disorders in selected patients with a diagnosis of VTE is not warranted. This is because in most patients with VTE, the identification of an inheritable disorder does not alter therapeutic or prophylactic anticoagulation management and consequently has not been associated with improved outcomes.

In select populations this may be considered such as:  1) Patients with family history of VTE especially if documented before the age of 45, 2) Patients with recurrent thrombosis, 3) Patients with thrombosis in multiple venous sites or in unusual vascular beds (e.g., Portal, hepatic, mesenteric or cerebral veins), 4)  Patients with a history of warfarin - induced skin necrosis are at increased risk of Protein C Deficiency, or 5) Patients with arterial thrombosis.

This patient did not have these conditions.

Although testing in these select populations leads to the increased identification of hypercoagulable states, it infrequently alters the duration of anticoagulation or prevents VTE- related death.

Testing for MTHFR gene cannot be recommended.

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 current procedural terminology (CPT) code 81291 - 5, 10 methylenetetrahydrofolate reductase (MTHFR), gene analysis, common variants (e.g. 677T, 1298C) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I Occlusion
Treatment: braces
The insurer denied braces.  The health plan's determination is overturned. 

The patient in question is a female with a Class I occlusion. She has severe maxillary spacing and minor mandibular crowding. Teeth # (number)10 and #13 are missing. Tooth J is retained. She is treatment planned for braces. 

Braces are medically necessary. In order to correct her malocclusion, the space either needs to be closed orthodontically, or the space needs to be managed orthodontically to arrange the space, so that the missing tooth can be replaced with a prosthetic, be it an implant or a tooth-supported restoration. There is simply no way to address this problem that does not involve orthodontic intervention. Braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg swelling

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult with a past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, morbid obesity and obstructive sleep apnea who presented to the emergency department (ED) with complaints of right leg swelling and erythema. Vital signs on presentation included: temperature 37.6 degrees Celsius (C), blood pressure 159/79, pulse 91, respiratory rate 18, and oxygen saturation (O2) sat 100% (percent) on room air. Laboratory results included the following: white blood cells (WBC) 7.2, hemoglobin (Hgb) 14.0, hematocrit (Hct) 40.7, creatinine 0.55, glucose 111 and lactate 0.9. The patient was started empirically on intravenous (IV) antibiotics (Vancomycin and Zosyn) for right leg cellulitis. A lower extremity duplex ultrasound was negative for deep vein thrombosis (DVT). The patient's chief complaint was anxiety. Psychiatry was consulted and medications were initiated. Infectious Disease was also consulted. The patient remained afebrile and hemodynamically stable. The patient clinically improved and was discharged on oral antibiotics. 

Failure of outpatient antibiotics alone does not necessitate hospital admission. 

According to documentation, the patient presented with right leg pain for one month. Otherwise, the patient was afebrile, hemodynamically stable, and had unremarkable laboratory results including a normal WBC. There was no evidence of a disseminated infection and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management; an inpatient 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 of the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pulmonary embolus/heart strain
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

This case involves a man admitted to the hospital with intermittent left flank pain. The pain started while playing volleyball, and was sharp, 10 out of 10. The patient took some Percocet, which helped relieve some of the discomfort. Imaging was completed, which included computed tomography (CT) of the chest with contrast, revealing large pulmonary emboli of the pulmonary trunk, right main, and lobar pulmonary arteries, with smaller emboli on the left side. There was a straightening of the septum, consistent with borderline enlargement of the right atrium.

The inpatient hospital admission was medically necessary for this patient. Based on the provided documentation, the patient has a central pulmonary embolus, causing right heart strain per echocardiogram and septal flattening, both criteria for an inpatient admission. Patients with pulmonary embolism causing right heart strain often benefit from advanced cardiac therapies, such as direct catheter thrombolysis, which is an inpatient-only treatment. Deployment of resources is significantly higher than evaluation and treatment of peripheral pulmonary embolus without hemodynamic instability.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Minimally Invasive Lumbar Decompression (MILD) Procedure
The insurer denied Minimally Invasive Lumbar Decompression (MILD) Procedure.
The health plan's determination is upheld.

This is male patient with diagnoses that include Spinal Stenosis, Lumbar Region, with Neurogenic Claudication; Spinal Stenosis, Lumbar Region without Neurogenic Claudication. The records provided show the patient was recommended to undergo the MILD (Minimally Invasive Lumbar Decompression) Procedure.

Minimally Invasive Lumbar Decompression (MILD) Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Mild (minimally invasive lumbar decompression), from Vertos Medical, Inc., describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the mild procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (eg, without endoscopic or microscopic visualization of the work area). This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required. Due to the unknown impact of these limitations on health outcomes, RCTs (randomized controlled trials) in appropriate patients are needed to compare this new procedure with established alternatives."
This patient is noted to have complaints of persistent low back pain, although it appears that minimal treatment has been attempted. There was no documentation showing the patient has had any skilled physical therapy, chiropractic treatment, cognitive behavioral therapy, and has only attempted hydrocodone - acetaminophen and ibuprofen. Therefore, the requested procedure is not indicated.