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

Diagnosis: Gastroenteritis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient had alcoholic cirrhosis and presented with abdominal pain. She started on daily lactulose and developed diarrhea. She was afebrile and the vital signs were stable. She had a distended abdomen but there was no rebound or guarding, an abdominal computed tomography (CT) scan showed cirrhosis and a liver lesion could not be excluded. The Blood urea nitrogen (BUN) was 10 and the creatinine was 1.29. The potassium was 2.9 but then rose to 3.1. She was referred for outpatient follow up of her liver disease. 

Clinical indications for admission for Gastroenteritis per Milliman Care Guidelines (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe dehydration as manifested by acute renal injury with a rise in creatinine to 2 times the baseline, inability to maintain oral hydration after observation care, and a severe electrolyte abnormality. The severe electrolyte abnormality is defined as a potassium of less than 2.5 or a potassium of less than 3 with severe findings such as a cardiac arrhythmia. The patient did not have these conditions. 

This patient had cirrhosis and developed gastroenteritis. The cirrhosis was a chronic condition and there was no indication of acute liver decompensation or acute liver failure. She was treated for gastroenteritis with intravenous (IV) hydration and potassium replacement. However, IV hydration and potassium replacement could have been given with observation status. She responded to the treatment and improved. She did not meet MCG criteria for admission for Gastroenteritis. 

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 admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain
Treatment: Intraosseous basivertebral nerve ablation [CPT (Current Procedural Terminology) code 64628 and 64629]
The insurer denied coverage for intraosseous basivertebral nerve ablation (CPT code 64628 and 64629).
The denial is upheld.

This patient has chronic low back pain. He has tried Physical therapy and Chiropractic therapy. His medication trials have included Gabapentin, Tylenol and Flexeril.  On magnetic resonance imaging (MRI) the patient has Modic changes.  The request is for radiofrequency ablation (RFA) of the Basivertebral nerves (BVN).

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:

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

Urits et al (5) 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 RF ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

This procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of intraosseous basivertebral nerve ablation (CPT code 64628 and 64629) 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: Medical necessity
Decision: Upheld

Diagnosis: Finger Amputation

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is an adult with a history of a blind left eye, obstructive sleep apnea (OSA), benign prostatic hypertrophy (BPH), hepatomegaly, gastroesophageal reflux disease (GERD), hemochromatosis, cardiomegaly, hypertension, and glaucoma. The patient presented to the emergency room (ER) with complaints of a wound to the left pointer finger after a knife injury on one week prior to presentation. The patient underwent a micro exploration and washout. American Society of Anesthesiologists (ASA) score was 3. The patient was transferred to the post anesthesia care unit (PACU) after surgery. The patient was discharged the same day. 

The medical record did not substantiate the level of service provided. The facts were the patient was referred to the hospital because of bleeding from the finger. The patient was sent to the emergency room for a cauterization. The patient did not have pain. The patient did not have a fever. The physician performed an irrigation and debridement. The procedure was performed under local anesthesia and monitored anesthesia care (MAC). The operative duration was 30 minutes. There were no post-surgical complications. This type of operation is not complex nor extensive. There was limited surgery completed. 

The vital signs were stable. There was no report of ongoing bleeding. (Of note an operative report was not provided for review).

The patient did not require additional ongoing services. A hematology consult was completed with no specific recommendation other than follow up in one week if the patient was still bleeding. 

There were no extenuating circumstances to substantiate the acute admission to hospital. 

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

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

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

The patient is a female who presented with palpitations. The patient reported intermittent palpitations for 3 days prior to presentation. The patient also mentioned chest pain which lasted a few seconds to minutes and resolving spontaneously. The patient had history of palpitations previously. One of her cousins died suddenly at a young age and the patient had a 24 hour Holter monitor which was negative. There was a family history for arrhythmogenic right ventricular cardiomyopathy (ARVC), and sudden cardiac death.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with palpitations and family history for sudden cardiac death. Her troponin was elevated, but without delta wave (no peak and slope). The patient was stable with normal vital signs. Multiple imaging including echocardiogram, computed tomography angiography (CTA) , electrocardiogram (ECG) and chest x-ray (CXR) were unremarkable. The patient was discharged for continuous work up as outpatient. Because her condition was stable, and all work up was normal, beside elevated troponin, an inpatient admission was not medically necessary. Chronic troponin elevation was of uncertain significance.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic kidney disease. 
Treatment: Farxiga. 

The insurer denied Farxiga. The health plan's determination is overturned. 

The patient is a male with stage IIIa chronic kidney disease from focal segmental glomerulosclerosis. The patient has been treated with valsartan. His most recent labs demonstrated a creatinine of 2.3 with 2.6 g (grams) of proteinuria per day. Farxiga 5 milligrams (mg) tablet was prescribed. 

A formulary exception is indicated in this case. 

Farxiga is approved for chronic kidney disease in patients at risk for progression of disease, to reduce the risk of sustained glomerular filtration rate decline, end-stage renal disease, cardiovascular death, and hospitalization for heart failure. The medication was prescribed in this case for chronic kidney disease, and the patient is at significant risk for glomerular filtration rate decline and end-stage kidney disease. Jardiance is not approved for, or pharmacy compendia supported for treatment of chronic kidney disease and therefore is not an appropriate formulary alternative. The formulary drug would not be as effective as the non-formulary drug.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Generalized Anxiety Disorder
Treatment: Formulary exception for Vilazodone
The insurer denied the formulary exception for Vilazodone.
The denial is overturned.

The patient is an adult female diagnosed with generalized anxiety disorder. The patient's physician has prescribed vilazodone after failing to respond to doxepin, bupropion, fluoxetine, and escitalopram, as well as lorazepam.

The treatment with vilazodone has been denied coverage by the health plan based on coverage exclusion, as formulary alternative medications are available, and prior authorization criteria requires treating with formulary drugs before a coverage exception is allowed; the plan requires treatment failure with at least three alternative formulary medications prior to authorizing a coverage exception.

As indicated in the prior authorization questionnaire, the prescribing clinician is requesting a coverage exception for vilazodone indicating that formulary alternatives have been tried and failed as indicated in the clinical summary.

The health plan should cover the formulary exception for Vilazodone.

In this case, the patient has failed to respond to doxepin, bupropion, fluoxetine, and escitalopram, as well as lorazepam, all of which are formulary drugs. The services with vilazodone are in keeping with prevailing standards of medical practice for the conditions under treatment in this case with an evidence-base treatment. The requested services/treatment being provided in this case are clinically appropriate, and are backed by credible scientific evidence known to benefit patients with the conditions diagnosed in this case. Moreover, the plan's guidelines are met in this case. Additionally, the selection and use of vilazodone is targeting symptoms of anxiety, which is reasonable, in the best interest of the patient and provided with sound medical judgment. The formulary drugs outlined in the clinical summary have been ineffective for this patient and were not as effective as the requested non-formulary drug. The risk for adverse effects for this patient would be similar for formulary drugs and the non-formulary drug alike and would be managed by using the lowest effective dose.

In summary and in keeping the New York State instruction for this review, the requested benefit of vilazodone is reasonable and clinically appropriate regarding the patient's diagnosis and clinical features and treatment history, outlined in the submitted information. The requested benefit of vilazodone to treat generalized anxiety disorder is also in the patient's best interest and provided with sound medical judgment with a reasonable likelihood of a satisfactory clinical response, especially in view of the disparate mechanism of action of vilazodone versus the formulary alternatives suggested in the denial determination, or already tried and failed. Therefore, the requested treatment with vilazodone is considered medically appropriate in this case scenario and consistent with prevailing standards of professional practice, and the scientific literature and published guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Premature ventricular contractions
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is Overturned.

The patient is an adult female with a past medical history of hypertension, diabetes mellitus and obstructive sleep apnea and palpitations. The patient's work up revealed frequent ventricular premature beats and runs of non-sustained ventricular tachycardia during exercise. Attempts to treat with beta blocker resulted in bradycardia and periods of heart block. She was referred for electrophysiologic study and ablation of PVCs (premature ventricular contractions). Access was via femoral veins and right femoral artery. Mapping and ablation of left ventricular outflow tract PVCs (premature ventricular contractions) was successfully performed. In addition, implantable loop recorder was implanted for continued heart rhythm monitoring. The patient was admitted to the telemetry ward overnight for post procedure monitoring.

The inpatient admission was medically necessary.

This patient suffered from palpitations and runs of ventricular tachycardia while exercising. Diagnostic and therapeutic electrophysiologic study required complex three-dimensional mapping of the left ventricular outflow tract as well as delivery of radiofrequency ablation. The US (United States) National Inpatient Sample Database, recorded outcomes of over 1200 patients undergoing catheter ablation for ventricular arrhythmia and demonstrated that the average length of hospital stay was 4.7 days. (Reference 3)

Acute inpatient hospital admission was medically necessary in this case. Catheter ablation of PVCs (premature ventricular contractions) is associated with 3% rate of major adverse cardiac events and a 1.2% rate of moderate adverse events. (Reference 1) In one registry study, including more than 400 patients undergoing catheter ablation for PVCs (premature ventricular contractions), the median length of hospital stay post procedure was 3 days. (Reference 2) A third study, analyzing the US (United States) National Inpatient Sample Database, recorded outcomes of over 1200 patients undergoing catheter ablation for ventricular arrhythmia demonstrated that the average length of hospital stay was 4.7 days. (Reference 3)

In this case, the patient underwent a successful PVC (premature ventricular contraction) ablation without complication. However, inpatient hospitalization for close monitoring and treatment is indicated and in the best interest of the patient. In conclusion, this patient could not have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient ischemic attack
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This case involves an adult who presented to the emergency department with a history of iron deficiency anemia and complaint of left-sided facial, arm, and leg numbness.  She was in no acute distress and was alert and oriented x times) 3 (person, place and time).  The patient reported several year's history of similar episodes and endorsed a mild left temporal headache. She was evaluated prior for this same problem, had seen neurology, and had magnetic resonance imaging / magnetic resonance angiography (MRI/MRA), which were normal. She denied nausea, vomiting, diarrhea, chest pain, confusion, recent travel, deep vein thrombosis/pulmonary embolism, and denied any sick contacts.  She claimed to have photophobia with her vital signs normal. She reported a pain score of 7/10 with neurology examination noting left facial numbness, left arm and leg numbness, 3/5 left arm strength but no gait instability or facial asymmetry. She claimed to have left-sided numbness for several days.  

The treatment plan included electrocardiogram (EKG), urinalysis to confirm and/or rule out pregnancy, computed tomography (CT) of the head, analgesia plus Benadryl plus Reglan, laboratory testing and neurology consult. The report indicated likely outpatient management. Her pregnancy test was negative, CT was negative, with Glasgow Coma Scale 15. Her Braden scale score was 23 and during her further examination, she denied having pain. The patient was admitted for further work-up/care and remained in inpatient status until she left Against Medical Advice. She demonstrated sufficient capacity to understand the risks associated with doing so.

According to the Milliman Care Guidelines (MCG), the patient did not satisfy the criteria for inpatient admission regarding a transient ischemic attack. She was negative for pregnancy, suspected vasculitis, did not require prolonged cardiac telemetry monitoring, did not have severe hypertension, had no clinically significant cardiac or vascular disorders identified that required inpatient care nor does she have cardiac arrhythmias of immediate concern, altered mental status, findings on brain imaging that required inpatient care, with no focal neurologic signs recurring and she was not hemodynamically unstable.  

The patient could have had her care safely and effectively rendered on an observational or outpatient basis.

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: Upheld

Diagnosis: appendicitis
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is a female who presented with the complaint of abdominal pain of 1-day duration. She was evaluated with examination, labs, and imaging. This assessment revealed right lower abdominal tenderness and computed tomography (CT) findings of acute appendicitis. Vital signs were normal at the time of presentation. The white blood cell (WBC) count was elevated at 12. Surgical consultation was obtained. The patient was admitted to the hospital and started on IV antibiotics. She underwent surgical treatment for acute appendicitis (laparoscopic appendectomy).

The inpatient hospital admission was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated with a lower level of care without need for full inpatient admission.
This patient presented to the ED (Emergency Department) with abdominal pain. The evaluation with examination, lab data, and abdominal CT supported the diagnosis of acute appendicitis. The patient was treated with intravenous (IV) antibiotics and laparoscopic appendectomy. Following surgery, she was clinically stable and was tolerating a diet. She was discharged from the hospital with instructions for surgical follow up.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care designation would have provided for surgical assessment, performance of surgery, and provision of antibiotics. This lower level of care would have also allowed for overnight monitoring (if needed).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient hospital admission
The health plan denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male. He was admitted for lightheadedness and syncope.

On admission, the patient was found to have low blood pressure, and was started on IV (intravenous) fluid. His creatinine was elevated. Renal and Bladder ultrasound showed echogenic kidneys compatible with medical renal disease and right renal calculi. Foley catheter was placed.

Initial treatment plan included Nephrology Consult, continuous cardiac monitoring, continuous IV (intravenous) fluids, serial lab studies to trend troponins/electrolytes, VQ (ventilation/quantity of perfusion) scan, and orthostatic vital signs monitoring.

The patient's kidney function was better and blood pressure stabilized. He was discharged.

Per the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, the initial evaluation of syncope includes a careful history and physical examination and an ECG (electrocardiogram). The findings of this initial evaluation can often identify patients who are at low risk for a dangerous etiology (e.g. ["for example"], arrhythmia). Absent other indications for inpatient care, patients with presumptive reflex-mediated syncope (e.g., vasovagal syncope, carotid sinus syndrome, micturition syncope, cough syncope), or syncope due to orthostatic hypotension or dehydration can be managed in the outpatient setting. Patients at intermediate risk for a cardiogenic etiology (arrhythmia, valvular disease) can be further evaluated in an observation care setting, with need for inpatient admission determined by the results of testing and further evaluation (e.g., telemetry).

The patient was hemodynamically stable, with normal oxygenation and negative cultures. He did not have significant electrolytes disturbance or irreversible change in kidney function. He did not have cardiac arrhythmias or altered mental status.

Therefore, per medical society guidelines, inpatient hospital admission was not medically necessary, and observation level of care would have been more appropriate.