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

Diagnosis: Chronic neck pain

Treatment: Pain injection (62321 x 1)

The insurer denied coverage for pain injection (62321 x 1)

The denial is overturned
 

This patient has chronic neck pain. She has had Physical Therapy and massage therapy. Her medication trials have included Diclofenac, Percocet, Cyclobenzaprine, Lidocaine patch, and Gabapentin. Her magnetic resonance imaging (MRI) shows multi-level degenerative changes as well as foraminal stenosis. A prior Epidural Steroid injection (ESI) gave her 80% pain relief.  The request is for another Epidural steroid injection.

Clinical practice guidelines (1) and a Cochrane review (2) support the performance of an Epidural Steroid injection in this patient.  The evidence-based practice guidelines do not limit the therapy to one year.

Manchikanti et al (1) state: "Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness."

Olivera et al (2) concluded:

"A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term."

The injection is medically reasonable and necessary.

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 pain injection (62321 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Patient is an adult with a past medical history of congestive heart failure (CHF), coronary artery disease, diabetes, hypertension, hyperlipidemia, obstructive sleep apnea and asthma who presented to the emergency department (ED) with complaints of shortness of breath, dyspnea on exertion and leg swelling; for about 3 weeks but worse over last 2 days. He denied chest pain, fever or chills. 

Vital signs were within normal limits and oxygen saturation on room air was 98%. He was in no acute distress, no jugular venous distention documented. Lungs were clear, without rales or wheezes, heart sounds normal. Leg edema was reported to be non-pitting. He was alert and oriented x 3.

Lab results were within normal limits except for a mildly elevated Brain natriuretic peptide (BNP).
Electrocardiogram was normal sinus rhythm with occasional premature ventricular contractions.
Chest x-ray was positive for cardiomegaly, no infiltrates or consolidation.

Patient was given 1 dose of intravenous (IV) Lasix in ED. Subsequently he was treated with oral (PO) Lasix, bronchodilators and inhaled corticosteroids. He was admitted to the hospital for decompensated CHF. Echocardiogram resulted in an ejection fraction of 50 - 55%. Study for deep vein thrombosis was negative.

Patient remained stable after admission. Was tolerating PO. He was hemodynamically stable and in no acute distress. Subsequently discharged home after a few days. This patient did not need acute inpatient hospitalization. He could have been placed in observation while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours during which  he could have been stabilized and discharged home on PO meds with close follow-up as an outpatient .

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: idiopathic short stature (ISS)

Treatment: Nutropin AQ NuSpin 10

The insurer denied coverage for Nutropin AQ NuSpin 10

The denial is overturned

 
This is a teenager diagnosed with idiopathic short stature (ISS). This request is for Nutropin. As reported, she has passed her growth hormone (GH) stimulation test and she was started on GH therapy under the ISS diagnosis. Her height velocity on therapy is reported to be 5.8 centimeters per year (cm/yr). She is taking Nutropin 1.9 milligrams (mg). Her insulin like growth factor 1 (IGF1) was 47 (52-297 page 25). Her GH stimulation with clonidine and arginine peaked at 16.30. Her breasts and pubic hair were at tanner 3. 

Her recent weight was 104 lbs. Chart page 23 shows that her pretreatment height was more than 2.25 standard deviation (SD) below the mean with a slow height velocity.

Her height on therapy most recently was 160.1 cm (-0.11 SD)
Her mother's height is 161.29 cm and father's height is 170.18 cm and mid parental height is 159.235 cm (-0.63 SD).

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."[10-13]

The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria.

The patient is a continuing therapy patient. The patient continues to grow at an excellent rate on growth hormone. The time to discontinue growth hormone is once the patient's height velocity reduces to below 2 cm per year in the setting of puberty and a bone age of 15 or more.

The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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 Nutropin AQ NuSpin 10 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: eosinophilic esophagitis
Treatment: Dupixent 300 milligrams (mg) / 2 milliliter (ml) syringe
The insurer denied coverage for Dupixent 300 mg / 2 ml syringe
The denial is overturned.
 
The patient was having dysphagia. He had a history of an esophageal perforation following a food impaction. A previous endoscopy revealed eosinophilic esophagitis. A progress note stated that budesonide will be started. He was also seen recently and the medical record indicates that he was on budesonide at that time as well as pantoprazole. In addition, around that time he had another episode of dysphagia from a foreign body. 

Up To Date has an article titled "Treatment of Eosinophilic Esophagitis." The article discusses pharmacologic therapy. Both proton pump inhibitors (PPI) therapy and topical steroids such as budesonide are advised treatments. There are also options listed for non-responders. Dupilumab is an lnterleukin-4 receptor antagonist that has been approved for use in the treatment of eosinophilic esophagitis in patients over 12 years old. Studies have shown that Dupilumab resulted in improvement in dysphagia scores as measured by the Dysphagia Symptom Questionnaire. Its best use is for patients who are refractory to other options. 

This patient has a diagnosis of eosinophilic esophagitis and has remained symptomatic on a PPI and budesonide. He has had food impactions. The physician's letter and the insurance denial discuss treatment with Dupixent for asthma. However, in this case, the chart does document that the patient has eosinophilic esophagitis and has remained symptomatic on a PPI and topical steroid. Therefore, giving Dupixent to a patient with refractory symptoms is appropriate. 

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 Dupixent 300 milligrams (mg) / 2 milliliter (ml) syringe is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied: Intraosseous Basivertebral Nerve Ablation 
(64628)
The denial is Upheld.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed. The patient has failed conservative treatment in the form of PT (physical therapy), ESIs (epidural steroid injections), and medications. Magnetic resonance image shows degenerative endplate changes, which can be taken to mean Modic changes. The patient's physical exam does not reveal any neurological injury.

The health plan should not cover the Intracept procedure.

The requested Intracept procedure is not likely to be more beneficial than standard treatments. The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed. The patient has failed conservative treatment in the form of PT (physical therapy), ESIs (epidural steroid injections), and medications. Magnetic resonance image shows degenerative endplate changes, which can be taken to mean Modic changes. The patient's physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. 
It is a new 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 used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The procedure is a Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized clinical trials (RCT) with five-year results.
However, this patient has not failed or attempted all conventional and typical options for common causes of axial low back pain, including facet and sacroiliac interventions. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives do show favorable outcomes in the literature, have lower risk, 
and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied: Intraosseous Basivertebral Nerve Ablation 
(64628)
The denial is Upheld.

The patient is an adult male. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes. The patient had greater than 6 months of pain and failed treatment. The pain began 18 months prior. The patient had tried home exercises, injection, medication management and physical therapy.
Seven months ago, the patient presented with lumbar pain. The patient's exam revealed lumbar spine bilateral paraspinal tenderness with facet loading positive. Straight leg raise was positive bilaterally. Diagnosis includes lumbar radiculitis and vertebrogenic pain.

The health plan should not cover the requested health service.

Based on the documentation provided, the requested procedure should not be covered. There is lack of documentation of the patient having tried and failed all prior conservative treatments. As such, the request is not recommended in this case. The patient has other underlying potential causes of symptoms. Upon exam, it was noted the patient had positive axial loading, and MRI (magnetic resonance imaging) had demonstrated facet arthropathy at the levels being requested. There was no documentation of patient having tried and failed other interventional treatments prior to the requested Intracept procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm labor
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female who was sent to the hospital for threatened preterm labor. The patient was at 33 0/7 weeks gestation who presented with contractions. The patient was noted to have a large 7 centimeter (cm) lower uterine segment fibroid and had painful contraction and was admitted for rule out preterm labor. 

In this case, the care as rendered for the patient with threatened preterm labor would not have required admission to the acute inpatient level of care. The care as provided was appropriate for a lower level. In this case, the patient was noted to have absent cervical change and would not be indicated for magnesium for neuroprotection given gestational age beyond 32 weeks. She was indicated for antenatal corticosteroids and these were administered. After admission, intravenous (IV) fluids were given and the patient spaced out contractions. There was no cervical change over 4 exams. The health plan's determination of medical necessity is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other - Cervical Radiculopathy.
Treatment: Inpatient Hospital Stay.
The health plan denied: Inpatient Hospital Stay.
The determination is: Upheld.

The patient is a female with a recent diagnosis of diabetes mellitus (DM) who presented to the emergency department (ED) with one week of left arm pain and weakness. The pain radiated towards her chest for 1 day. She also reported palpitations and shortness of breath. She had a prior history of sinus tachycardia with cardiology evaluation and Holter, for which there was no necessary intervention. Her vital signs were stable upon presentation. The physical exam was notable for 4/5 strength in the left upper extremity (LUE) in the ED, but the spine note documented she was without weakness or deficit. A computed tomography (CT) scan of the cervical spine was performed which showed reversal of the normal cervical lordosis and cervical 4/5 (C4/5) left disc protrusion. An electrocardiogram (EKG) and cardiac enzymes were within normal limits, and cardiac etiology was ruled out. Neurology and spine were consulted. They both recommended cervical magnetic resonance imaging (MRI) with a presumed diagnosis of cervical radiculopathy.
The patient was given intravenous (IV) steroids, narcotics, and oral Flexeril for pain control. Her home Metformin was stopped, and a sliding scale for insulin was initiated for blood sugar control given diabetes and steroid use. The cervical MRI demonstrated a small central disc osteophyte complex and annular tissue with mild canal narrowing at C4/5, with no other abnormalities. The patient was discharged home with oral Tylenol, oral steroids, and home medication Metformin. She was recommended for outpatient follow-up.
At issue is the medical necessity of the inpatient stay.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient admission stay was not medically necessary for this patient.
The patient is a diabetic female who presented with cervical radiculopathy. The physical exam initially demonstrated some LUE weakness, which improved with pain control and steroids. Imaging demonstrated mild findings at C4/5 without acute surgical pathology. She was discharged home safely with pain control and outpatient follow-up. No inpatient needs were present. The patient could have safely been treated at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, peripheral artery disease, and deep vein thrombosis
Treatment: Inpatient hospital services
The insurer denied coverage for inpatient hospital services.
The denial is upheld.

Patient is an adult female with past medical history significant for hypertension, peripheral artery disease, and deep vein thrombosis on Eliquis who presented to the emergency department with complaints of a chronic non-healing left leg ulcer.

Vitals on presentation included: Temperature 98.8 degrees Fahrenheit, Blood Pressure 140/75, Pulse 82 beats per minute, Respiratory Rate 16 breaths per minute, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell count (WBC) 6.2, hemoglobin (HGB) 13.2, hematocrit (HCT) 42.2, creatinine 0.9, glucose 116.

The patient was admitted for a chronic leg ulcer. She was started on broad-spectrum intravenous antibiotics (vancomycin, cefepime and metronidazole). The wound culture of the leg grew multiple bacteria including Klebsiella oxytoca, Morganella morganii, alpha-hemolytic Streptococcus, and Bacteroides fragilis. X-ray of tibia/fibula showed no evidence of osteomyelitis. The patient underwent a bedside 5-millimeter punch biopsy to rule out pyoderma gangrenosum. The patient remained afebrile and hemodynamically stable during the admission. She was discharged to continue outpatient management.

According to documentation, the patient had no evidence of a disseminated infection. Based on the above findings, the patient met criteria for observation level of 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 inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic kidney disease and hyperkalemia
Treatment: Veltassa 8.4 Gram Powder Pack
The insurer denied: Veltassa 8.4 Gram Powder Pack
The denial is upheld.

The patient is an adult female with chronic kidney disease and hyperkalemia. The treating physician requested Veltassa to improve potassium level.

The Veltassa is not medically necessary.

This patient with elevated potassium level and will benefit from potassium binder in addition to low potassium diet. However, the health plan's available alternative (Lokelma) is safe and effective in treating this patient's condition.
The medical records did not show that the patient has tried and failed Lokelma. The treating provider stated that Lokelma is contraindicated due to volume overload. However, this is not an FDA (United States Food and Drug Administration)-recognized contraindication. In clinical trials, sodium load related to Lokelma was not considered to be significant. Therefore, given the above, the requested Veltassa is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Services
The insurer denied: Inpatient Hospital Services
The denial is: Overturned

The patient is a male with a liver transplant, on immunosuppression, who presented to the hospital with abdominal pain and an inability to tolerate food for two weeks. He complained of poor appetite and nausea with a small amount of emesis. He also had some diarrhea for several days. He was evaluated in the emergency department (ED) with computed tomography (CT) abdomen pelvis, worrisome for early small bowel obstruction. He was initially admitted to the hospital for monitoring but eloped because he wanted to eat. He returned to the hospital with ongoing symptoms. Vital signs appeared relatively stable, with a temperature of 37.7  Celsius (C), respirations of 17, and blood pressure of 105/53. On exam, the patient is oriented x 3 (person, place and time), with left lip droop, which is chronic. The abdomen was soft, without detectable tenderness or palpable masses. The cardiopulmonary exam was unremarkable.

Inpatient hospital services were medically necessary in this patient with immunosuppression, who developed abdominal discomfort, diarrhea, acute kidney injury, and persistent hyperkalemia. Patients post-transplant are significantly immunosuppressed and at risk for developing CMV colitis and other opportunistic infections. It can lead to severe systemic infections, rejection of the transplant, and death. Transplant patients require close monitoring and can rarely be evaluated and treated rapidly in an observation level of care. This patient, in particular, had multiple electrolyte derangements, including persistent hyperkalemia, acute kidney injury on chronic kidney disease, and persistent diarrhea, which prevented rapid evaluation and treatment with further outpatient care. He required prolonged hospitalization to rule out abdominal pathogenic infections, intravenous (IV) fluid hydration, correction of the hyperkalemia, and monitoring for signs of organ rejection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Services
The insurer denied: Inpatient Hospital Services
The denial is: Overturned

The patient is a male with a liver transplant, on immunosuppression, who presented to the hospital with abdominal pain and an inability to tolerate food for two weeks. He complained of poor appetite and nausea with a small amount of emesis. He also had some diarrhea for several days. He was evaluated in the emergency department (ED) with computed tomography (CT) abdomen pelvis, worrisome for early small bowel obstruction. He was initially admitted to the hospital for monitoring but eloped because she wanted to eat. He returned to the hospital with ongoing symptoms. Vital signs appeared relatively stable, with a temperature of 37.7  Celsius (C), respirations of 17, and blood pressure of 105/53. On exam, the patient is oriented x 3 (person, place and time), with left lip droop, which is chronic. The abdomen was soft, without detectable tenderness or palpable masses. The cardiopulmonary exam was unremarkable.

Inpatient hospital services were medically necessary in this patient with immunosuppression, who developed abdominal discomfort, diarrhea, acute kidney injury, and persistent hyperkalemia. Patients post-transplant are significantly immunosuppressed and at risk for developing CMV colitis and other opportunistic infections. It can lead to severe systemic infections, rejection of the transplant, and death. Transplant patients require close monitoring and can rarely be evaluated and treated rapidly in an observation level of care. This patient, in particular, had multiple electrolyte derangements, including persistent hyperkalemia, acute kidney injury on chronic kidney disease, and persistent diarrhea, which prevented rapid evaluation and treatment with further outpatient care. He required prolonged hospitalization to rule out abdominal pathogenic infections, intravenous (IV) fluid hydration, correction of the hyperkalemia, and monitoring for signs of organ rejection.