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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who was referred to the emergency department (ED) by his cardiologist. He had recently undergone myocardial perfusion imaging (MPI) for two weeks of intermittent chest/epigastric pain. The MPI suggested mild inferolateral ischemia. An electrocardiogram at that time showed a left bundle branch block (LBBB) that was new. When the patient had recurrent pain he was referred to the emergency department (ED) for admission for cardiac catheterization. His past medical history was remarkable for hypertension. His electrocardiogram showed a left bundle branch block (LBBB) without acute changes. His serum troponin level was normal and remained normal when re-measured. The patient was treated with aspirin and sublingual nitroglycerin and was admitted to the hospital. He complained of upper respiratory congestion and an occasional cough. Testing was positive for human metapneumovirus. Coronary angiography showed mild nonobstructive coronary artery disease. He was discharged. At issue is the medical necessity for an inpatient admission.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with chest pain after recent myocardial perfusion imaging suggested inferolateral ischemia. There was concern 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 no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for his chest pain did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
While hospitalized, the patient reported upper respiratory symptoms and tested positive for human metapneumovirus. He was afebrile and no treatment was required. This did not warrant an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic breast cancer
Treatment: Radiation therapy
The insurer denied coverage for: Radiation therapy
The denial is: Upheld

This is the case of an adult with metastatic breast cancer. The patient was treated with stereotactic radiosurgery (SRS) for solitary brain metastasis. This was followed by palliative radiation therapy (RT) to posterior fossa. The patient now presents with leptomeningeal disease in the cauda equina and conus medularis. The plan is to consider proton beam to the craniospinal axis. This is the subject of review.
This patient has a palliative condition and disease is localized in the cauda equina and conus which can be treated with conventional palliative RT.
The patient was previously treated to brain with stereotactic radiosurgery (SRS) and palliative radiation therapy (RT) to the posterior fossa. Additional RT to the craniospinal axis will cause more toxicity to the brain. Palliative RT should be done to the area of the cauda and conus which was NOT treated before.
There are no published randomized data comparing intensity modulated radiation therapy (IMRT) and proton beam therapy (PBT) for leptomeningeal disease which is highly palliative with a poor prognosis.
In this case, the disease was in the cauda equina and conus so there is no need to treat entire craniospinal axis.
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 radiation therapy for brain metastases Is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Seizure
Treatment: Video EEG (95720 and 95716)
The insurer denied: Video EEG (95720 and 95716)
The denial is upheld.

The patient is an adult female with epilepsy. Her first seizure was several years ago. She had a similar event a few years ago. She had 3 more episodes a few years ago. She was treated with Keppra and later Briviact. A magnetic resonance image (MRI) of the brain was normal. Ambulatory electroencephalogram (EEG) was performed a few years ago which showed right frontal temporal paroxysmal activity with slowing. An ambulatory electroencephalogram (EEG) a few years ago showed right frontal temporal slowing. Another ambulatory electroencephalogram (EEG) was normal. This review is in regard to the ambulatory electroencephalogram (EEG) from last year. The plan denied coverage as experimental or investigational. This was appealed with a form stating that the standard health services have been ineffective or would be medically inappropriate and the physician recommended a health service based on 2 documents of medical and scientific evidence and cited 2 studies. This review is in regard to ambulatory electroencephalogram (EEG) use.

The health plan should not cover the proposed treatment. 

The requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. The patient had known epilepsy. The patient had 2 prior abnormal electroencephalogram (EEG) studies. Per standards of care, repeating ambulatory electroencephalogram (EEG) may be necessary in certain occasions, such as a change in clinical status, new seizures, new abnormalities on exam, and uncontrolled seizures that need further evaluation including as part of a surgical evaluation (Omidi, Cho). There is a single clinic visit note that summarizes the care. The note does not address why the ambulatory electroencephalogram (EEG) was necessary after the patient had 2 prior abnormal ambulatory electroencephalogram (EEG) studies. The note does not discuss the need for ambulatory electroencephalogram (EEG) for a
change in clinical status, new seizures, new abnormalities on exam, and uncontrolled seizures that need further evaluation including as part of a surgical evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Seizure
Treatment: Video EEG (95720 and 95716)
The insurer denied: Video EEG (95720 and 95716)
The denial is overturned.

The patient is an adult female with a history of seizures. Onset was several years ago. She also has a family history of seizures. She has been on Brivact. An electroencephalogram (EEG) a few years ago showed right frontal temporal slowing consistent with seizure focus. Ambulatory electroencephalogram from last year did not show any epileptiform activity. She is felt to have localization related symptomatic epilepsy with complex partial seizures. The ambulatory electroencephalogram performed was previously denied as plan requires the following in order for this to be covered: classification seizure type; diagnosis of seizure disorder; and localization of epileptogenic focus for presurgical evaluation.

The health plan should cover the proposed treatment.

Although the patient does not meet plan criteria as she already has a diagnosis of seizures that are classified as localization related seizures and is not pending surgery for seizures, indications for ambulatory electroencephalogram (EEG) include detection of interictal epileptiform discharges, capturing seizure events, detection of unrecognized seizures, and monitoring interictal epileptiform discharges during treatment, which all apply to this patient. Therefore, ambulatory electroencephalogram is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Seizure
Treatment: Video EEG (95720 and 95716)
The insurer denied: Video EEG (95720 and 95716)
The denial is upheld.

The patient is an adult female with seizure disorder who had an ambulatory electroencephalogram (EEG). Previous ambulatory 
electroencephalogram was completed a few years ago showed localize paroxysmal activity in the right frontal temporal area with slowing. Repeat ambulatory electroencephalogram a year was normal.

The health plan should not cover the proposed treatment.

It is not clear why a repeated ambulatory electroencephalogram was performed. There was no documentation of repeated, frequent spells that required monitoring for determination of etiology (1). The patient already had a diagnosis of seizure disorder. She was already treated with medication for seizures, and she was not reporting recurrent breakthrough events. The ambulatory electroencephalogram had no clinical utility here. 
Therefore, the health plan should not cover the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: pain management
The insurer denied Intraosseous Basivertebral Nerve Ablation
The health plan's determination is upheld. 

The patient is a male with complaints of chronic low back pain. The pain began 8 years ago approximately. The patient's prior treatments have included acupuncture, lumbar injections, massage therapy, as well as chiropractic care. The patient has tried multiple medications, including opioids. The pain significantly impacts activities of daily living and is rated on average 8 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type I and 2 changes at disc spaces L (lumbar) 3-4 and L4-5.

The proposed Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: pain management
The insurer denied Intraosseous Basivertebral Nerve Ablation
The health plan's determination is upheld. 

This is a male patient diagnosed with low back pain. Records show that the patient was recommended to undergo Intraosseous Basivertebral Nerve Ablation (Intracept procedure). The provider notes the patient's low back pain began 8 years ago and is rated at 8 out of 10 (8/10). He has tried multiple treatments including acupuncture, chiropractic, injections, massage therapy, radiofrequency ablation enter point injections. Medications have included baclofen, cyclobenzaprine, meloxicam and oxycodone. Pain is impacting activities of daily living. It was noted the patient had an magnetic resonance imaging (MRI) performed that demonstrated Mixed Modic type I and II changes at disc spaces L (lumbar)3 - L4 and L4 - L5 and the provider believes that this is the source of the patient's chronic back pain.

Intraosseous Basivertebral Nerve Ablation 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.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes. Although there is noted to be new Modic changes on MRI, there was also noted to be other findings that are likely pain generators including nerve root impingement at the exiting L4 nerve root.
This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure. The requested procedure is not indicated for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: pain management
The insurer denied Intraosseous Basivertebral Nerve Ablation
The health plan's determination is upheld. 

This is a male who has chronic neck and low back pain. His low back pain is more severe at night, especially turning in bed. He has frequent spasms in the lower back pain especially on the left side. He tried acupuncture, chiropractor care, and massage therapy with relief. He had 6 month of pain relief from a prior lumbar L (lumbar)3-L5 RFA (radiofrequency ablation), and 10 days pain relief from trigger point injections in the lower back. Physical exam (PE) showed lumbar spine decreased range of motion (ROM) with pain on flexion on the left side. Magnetic resonance imaging (MRI) showed Modic 1 end plates changes at L3-4 and L4-5, grade 1 retrolisthesis of L2 on L3 and a left foraminal disc herniation impinging exiting L4 nerve root. 

The proposed Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intraosseous Basivertebral Nerve Ablation (Intracept) was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has low back pain with left side muscle spasm. He responded well to the prior RFA. MRI reports documented grade 1 retrolisthesis of L2 on L3 and a left foraminal disc herniation impinging exiting L4 nerve root. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic pain. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. Based upon this patient's MRI findings, response to prior treatments, and the extrusion criteria of the current clinical studies on the Intracept procedure, it is not likely to be more beneficial for this patient than standard treatments.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Dry Eye Syndrome
Treatment: Formulary exception for Miebo 1.3GM (gram)/ML (milliliter) Drops
The insurer denied: Formulary exception for Miebo 1.3GM (gram)/ML (milliliter) Drops
The denial is overturned.

The patient is an adult female with dry eye syndrome for whom coverage of non-formulary Miebo is the subject of review. Coverage was previously denied by the health plan, as it was not identified that the patient had failed or could not use the formulary alternative, Restasis (cyclosporine). An exam note documents complaints of gritty, burning, and watery eyes which feel worse at the end of the day. Reportedly, the patient has been on Restasis in the past. The patient is also identified as having facial rosacea for which she uses wipes. Both corneas were reported as clear. It was recommended that the patient start Cequa and Miebo as well as artificial tears. Blink breaks were recommended, and the patient could consider IPL (intense pulsed light) treatment.

The health plan should cover the Formulary exception for Miebo.

The Preferred Practice Patterns of the American Academy of Ophthalmology recommend the use of topical cyclosporine (Restasis, Cequa) for patients with dry eye syndrome who have failed to respond to ocular lubricants. More recently, Miebo (perfluorohexyloctane ophthalmic solution) was FDA (United States Food and Drug Administration) approved for the treatment of the signs and symptoms of dry eye disease. In this case, documentation provided states that the patient has already tried Restasis. Therefore, the medical appropriateness of the requested Miebo is established per standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia, Dizziness
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of transfusion dependent anemia secondary to uterine leiomyoma who was admitted with complaints of (c/o) dizziness and anemia associated with fatigue with chronic light vaginal bleeding. The physical exam was notable for epigastric tenderness. Lab work was notable for hemoglobin 5.9, ferritin 6. Imaging studies included a chest x-ray (CXR) which showed no focal consolidation, a pelvic ultrasound (US) which showed multiple fibroids. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with symptomatic anemia and treated with intravenous (IV) iron, 2 units of packed red blood cells (PRBCs) and gynecologic (GYN) consultation. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o dizziness and anemia associated with fatigue with chronic light vaginal bleeding. The patient was found to have a low hemoglobin but had no history of hematochezia, hematemesis, or melena. She received two units of packed red blood cells (PRBCs), symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR)), coagulopathy, or known esophageal varices. The patient was noted to have bleeding while in the ED, but it was her chronic light bleeding that ultimately transitioned to a light spotting. This patient could have been safely observed and received diagnostic work-up, consultation and transfusion at a lower level of care.
Regarding the provided criteria, the patient did not have clinically significant uncontrollable active bleeding.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 Braces, D8670 Monthly Visit, D8680 Retainer
The insurer denied: D8080 Braces, D8670 Monthly Visit, D8680 Retainer
The denial is overturned.

This patient is a teenage female. The request is for orthodontic benefits with monthly visits and a retainer. She has a skeletal Class I malocclusion with severe upper and lower crowding. The prior denial was due to having 21 points on the handicapping index scale.

The requested health service is medically necessary.

The patient has a crossbite of a permanent anterior tooth (mandibular left canine) with gingival attachment loss. This is an automatic qualifier according to the handicapping index scale. 
Orthodontic treatment is needed to correct this problem. The monthly visits are to make sure treatment is progressing properly and the retainer is to prevent relapse at the end of treatment. 
This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID 19 Pneumonia
Treatment: inpatient stay
The insurer denied inpatient stay
The determination is overturned.

The patient is a male with a past medical history (PMH) of hyperlipidemia (HL) who was admitted with complaints of (c/o) severe sore throat associated with cough and shortness of breath (SOB). The physical exam notable for non-toxic appearing, injected oropharynx. Lab work was notable for coronavirus positive (COVID+). Imaging studies, a chest x-ray (CXR) showed right lower lobe (RLL) pneumonia. The patient was diagnosed with COVID-19 pneumonia and treated with remdesivir, oxygen supplementation, and steroids. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The medical stay was medically necessary at an acute inpatient level of care. This patient presented to the ED with severe sore throat associated with cough and SOB and was found to have symptomatic COVID-19 infection and sepsis associated with tachycardia, hypotension, and new hypoxia. The National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with an oxygen saturation of less than (<) 94 percent on room air. In addition, this patient's 4C [Coronavirus Clinical Characterization Consortium Mortality Score] mortality score was 8, indicating the patient was not at low-risk of in-hospital mortality, further informing the need for a higher level of care than outpatient. This patient was at risk of decompensation and required an acute inpatient level of care for safe medical treatment and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Cardiac.
inpatient hospital.

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

This case involves a man with polysubstance abuse admitted to the hospital with chest pain. The patient developed sharp, squeezing chest pain after ingesting cocaine. He has had similar episodes in the past, resulting in admissions to different hospitals. An electrocardiogram (EKG) showed no acute ST-segment elevations. Vital signs showed normal temperature, heart rate of 80, and blood pressure of 117/66. Examination showed normal cardiopulmonary findings, redness to the bilateral conjunctiva, and midline abdominal scar.

Based on the provided documentation, inpatient admission was not medically necessary. The patient had a mild troponin leak in the setting of ongoing cocaine and alcohol use. This is typical and directly attributed to cocaine use. There was no evidence of an acute coronary syndrome. The echocardiogram showed no evidence of new regional wall motion abnormality or change in the ejection fraction. There was no evidence of alcohol withdrawal. Cocaine effects are transient, and as the drug was metabolized in the patient's system, the troponin decreased to normal levels. No further cardiac workup was completed. A lower level of care could adequately address the patient's symptoms.