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

Diagnosis: cerebral vascular accident (CVA)
Treatment: custodial care/long term care admission
The insurer denied coverage for custodial care/long term care admission
The denial is overturned
 
The patient is an adult female with past a medical history significant for uncontrolled type II diabetes and glaucoma (with right eye blindness), who had a stroke with left hemiparesis. The patient was treated and was admitted to a sub-acute rehabilitation facility.

The patient's nursing home records indicate that she is unable to administer her own insulin (due to visual impairment), requires cues to complete tasks such as dressing and bed mobility, and has limited use of her left hand. The patient has an unsteady gait and follows simple commands. The patient did score within normal limits on a simple cognitive and memory test (BIMS or Brief Interview for Mental Status). This does not rule out cognitive impairments in executive function, concentration, and judgement.

At this point in the patient's recovery (almost six months out from an acute stroke), the patient is not expected to improve her functional scores substantially. Because the patient continues to need assistance with basic activities of daily living (ADLs), such as dressing and bathing, and is unable to administer her own medications (including insulin), she is appropriate for a Long-Term Care facility.

Per Murphy & Werring (2020) "Stroke is a clinically defined syndrome of acute, focal neurological deficit attributed to vascular injury (infarction, haemorrhage) of the central nervous system. Stroke is the second leading cause of death and disability worldwide. Stroke is not a single disease but can be caused by a wide range of risk factors, disease processes and mechanisms. Hypertension is the most important modifiable risk factor for stroke, although its contribution differs for different subtypes. Most (85%) of strokes are ischaemic, predominantly caused by small vessel arteriolosclerosis, cardioembolism and large artery athero-thromboembolism. Ischaemic strokes in younger patients can result from a different spectrum of causes such as extracranial dissection. Approximately 15% of strokes worldwide are the result of intracerebral haemorrhage, which can be deep (basal ganglia, brainstem), cerebellar or lobar. Deep haemorrhages usually result from deep perforator (hypertensive) arteriopathy (arteriolosclerosis), while lobar haemorrhages are mainly caused by cerebral amyloid angiopathy or arteriolosclerosis. A minority (about 20%) of intracerebral haemorrhages are caused by macrovascular lesions (vascular malformations, aneurysms, cavernomas), venous sinus thrombosis or rarer causes; these are particularly important in young patients (< (less than) 50 years). Knowledge of vascular and cerebral anatomy is important in localizing strokes and understanding their mechanisms."

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 custodial care/long term care admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.  
The denial has been upheld.

The proposed treatment was not medically necessary.

The patient is a female with hypertension and nephrolithiasis who presented to the emergency room with left sided chest pain for four weeks. The patient was found to have left sided pleural effusion. The patient was admitted to the hospital for further management. The patient underwent thoracentesis during the hospitalization. The patient received pain medications
as well as continued on home blood pressure medication. The hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The patient was diagnosed with left pleural effusion. The patient was treated with antibiotics as an outpatient but they did not help. At the time of admission, the patient was hemodynamically
stable. The patient was not on any invasive drips. The patient was tolerating oral diet. The patient was awaiting thoracentesis. The patient did not received any treatment that could not have been provided at a lower level of care. The proposed 
 hospitalization was not medically necessary.

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

The patient did not receive any treatment that could not have been provided at a lower level of care. The proposed hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Surgical Procedure on the Stomach (laparoscopic sleeve gastrectomy). 

The insurer denied coverage for Surgical Procedure on the Stomach (laparoscopic sleeve gastrectomy). 

The denial is overturned. 
 
According to the documentation provided this is an adult who was being evaluated for bariatric surgery. As per the progress note the patient was undergoing medical evaluation for upcoming bariatric surgery. Body Mass Index (BMI) was 36.65. The patient did not have any other significant medical history except for obesity. The patient was cleared for bariatric surgery. 

Based upon the records provided Milliman Care Guidelines (MCG) the patient does meet the criteria and indications for bariatric surgery. According  to MCG Health Inpatient and Surgical Care 27th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy ORG: S-516 (ISC)  the procedure is indicated by ALL of the following: Severity of obesity judged appropriate for procedure, as indicated by 1 or more of the following: Adult patient has BMI of 35 or greater (32.5 or greater in Asian patients); Adult patient has BMI of 30 to 34.9 (27.5 to 32.4 in Asian patients) and ALL of the following: Clinically serious condition related to obesity (e.g., type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe lower extremity osteoarthritis, treatment-resistant hypertension); Failure of nonsurgical therapy, as indicated by 1 or more of the following: Inadequately controlled hyperglycemia despite optimal diabetic treatment, Positive airway pressure therapy not effective or not tolerated for obstructive sleep apnea or obesity hypoventilation, Treatment-resistant hypertension, Other serious obesity-related condition insufficiently responsive to nonsurgical treatment (e.g., nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe osteoarthritis); Patient support programs. Thus, the patient meets the current revised guidelines as her BMI was greater than 35. In terms of the insurer denying based upon the weight and lack of co morbidities- this is no longer the guidelines as per MCG. As long as the BMI is greater than 35 and the patient has met the other requirements, the patient is then a candidate for weight loss surgery. Therefore, the patent does meet the guidelines for bariatric surgery. 
	
The denial is reversed, and coverage should be provided for sleeve gastrectomy. Based upon the records submitted, the patient does meet criteria for bariatric surgery as the patient does have a BMI greater than 35. 

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 a Surgical Procedure on the Stomach (laparoscopic sleeve gastrectomy) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral vascular disease
Treatment: Ambulatory Procedure - Vein Procedure: Femoral and Popliteal Artery Interventions 
The insurer denied Ambulatory Procedure - Vein Procedure: Femoral and Popliteal Artery Interventions. The health plan's determination is overturned. 

The patient is a man with hypertension, diabetes, hyperlipidemia, peripheral vascular disease, status/post (s/p) right above knee amputation, who presented with left leg pain. The patient stated that the leg pain had been getting worse and had started more than a year ago.

The Ambulatory Procedure - Vein Procedure: Femoral and Popliteal Artery Interventions is medically necessary for this patient. The patient has peripheral arterial disease, left lower extremity rest pain requiring treatment. The treatment, left lower extremity angiogram, left anterior tibial artery atherectomy and angioplasty is medically necessary. The treatment is the standard of care for the treatment of peripheral arterial disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Possible Carotid Obstruction
Treatment: Duplex scan of extracranial arteries
The health plan denied the requested Duplex scan of the extracranial arteries as not medically necessary.
The health plan's determination is overturned.

The patient is a man with hyperlipidemia, obstructive sleep apnea, and asthma. He underwent a Duplex scan of the extracranial arteries. No significant plaque was detected. Per a letter from his physician, the indication for the study was a carotid bruit auscultated on physical exam.

At issue is the medical necessity for the requested health service/treatment of a Duplex scan of the extracranial arteries.

I overturn, in whole, the health plan's determination that this service was not medically necessary in this instance.

A carotid bruit is a vascular sound heard over the carotid arteries that indicates turbulent, nonlaminar blood flow in the vessel. The presence of a carotid bruit predicts hemodynamically significant carotid stenosis in up to 20% (percent) of patients. Significant carotid stenosis is a risk factor for ischemic cerebrovascular events and cognitive impairment. Interventions, including pharmacologic treatments, lifestyle intervention, and surgery, have been shown to mitigate this risk. Per the Society for Vascular Surgery, imaging screening for carotid disease in asymptomatic patients has been found to reduce the risk for stroke in a cost-effective manner when the prevalence of significant stenosis is 20% or greater. Thus, the 2022 Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease endorses the use of carotid Duplex imaging in asymptomatic patients with carotid bruits heard on physical exam.

The AIM Specialty Health guideline for vascular imaging was provided for review. An asymptomatic carotid bruit was not listed as an indication for carotid Duplex imaging. However, as mentioned above, the 2022 Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease endorse the use of carotid Duplex imaging in asymptomatic patients with carotid bruits heard on physical exam.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain. 
Treatment: Diagnostic or therapeutic injection (code 62323). 
The insurer denied coverage for diagnostic or therapeutic injection (code 62323). 
The denial is overturned. 

The patient had (Lumbar) L5/S1 (Sacral) fusion and placement of an artificial disc at that level. Pain was rated at a level of 4 out of 10. The patient tried and failed physical therapy (PT). The Magnetic Resonance Imaging (MRI) shows that the artificial disc extends into the canal and indents the thecal sac. 

The insurer has denied coverage for diagnostic or therapeutic injection (code 62323), as not medically necessary. In a Final Adverse Determination letter, they stated that in order to approve this service the insurance would need a treatment plan that shows the requested injection will not exceed one level of the spine when injecting the space near the spinal canal; a caudal approach should not be done for nerve problems above the L4-L5 spinal level. 

The patient has a probable pain generator in the protruding artificial disc at L5-S1. 

Epidural steroid injections are evidence-based interventions (1) when addressing a pain generator at the L5-S1 level. 

Similarly, a recent Cochrane review (2) stated: 

"Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up [mean difference (MD) - (minus) 4.93, 95% (percent) confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, (number of participants) n = 949; moderate-quality evidence (downgraded for risk of bias)]. For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up [MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = (equal) 1367; moderate-quality evidence (downgraded for risk of bias)]. The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (such as MD lower than 10%)." 

The requested procedure is medically reasonable and 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 diagnostic or therapeutic injection (code 62323) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Wegovy. 
The insurer denied: Wegovy. 
The denial is overturned. 

This adult female patient has a diagnosis of obesity. The denial of Wegovy is being appealed. The patient's body mass index is 38.3. Her comorbid conditions include hyperlipidemia. She is currently on a reduced calorie diet and exercise program. The 
medication will not be used with other weight loss products. 

The proposed treatment is medically necessary. 

Wegovy is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 or greater or 27 or greater in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia). This patient's body mass index is 38.3. 

The requested Wegovy is medically necessary because it is consistent with accepted medical standards for this member who has a body mass index greater than 30 and is currently on a reduced calorie diet and exercise program.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertensive encephalopathy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


This is an elderly woman with a history of hypertension that presented to the hospital following a syncopal episode.  She was seated on the couch and lost consciousness. Family members attempted to perform cardio-pulmonary resuscitation (CPR) until emergency medical services arrived.  She awoke after a five minute period.  Upon arrival to the hospital she was hypertensive with a Blood Pressure of 204/88 mmHg and a pulse of 77 bpm.  Physical examination was unremarkable and no focal findings were noted on neurologic examination.  12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with a normal QTc interval (420msec) and without ischemic ST or T (intervals on an EKG) wave abnormalities.  Serum blood testing revealed acute renal insufficiency with a creatinine of 1.63 mg/dl and a potassium of 5.2 Meq/L.  The patient was treated with intravenous hydralazine but remained hypertensive.  She was admitted to the hospital to treat hypertensive encephalopathy. Echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 50% without severe valvular heart abnormality.  Following adequate treatment of blood pressure, creatinine recovered and the patient was discharged home. 

Patients presenting with loss of consciousness and acute renal insufficiency should be treated for hypertensive urgency/emergency and require urgent inpatient care. (Reference 1) According to American Heart Association/ American College of Cardiology/ Heart Rhythm Society  (AHA/ACC/HRS) guidelines patients with systolic BP over 180 mmHg and evidence of target organ damage (Central Nervous System and renal in this case) should be evaluated and treated in a hospital setting. (Reference1- 2)  Although patients presenting to the hospital with syncope can often be rapidly discharged, those with cardiac syncope are at high risk for future events that result in increased morbidity and mortality. (References 2,3,4) Admission to the hospital for observation and treatment was medically necessary in this case.

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic facial lipodystrophy of his bilateral cheeks

Treatment: Dermal Injections for treatment of facial lipodystrophy - outpatient procedure

The insurer denied coverage for dermal Injections for treatment of facial lipodystrophy - outpatient procedure

The denial is overturned
 
Patient is an adult with a past medical history significant for chronic immunodeficiency and chronic facial lipodystrophy of his bilateral cheeks.

At issue is medical necessity of dermal injections (Sculptra) for treatment of facial lipodystrophy - outpatient procedure. 

Chronic immunodeficiency associated lipodystrophy refers to changes in fat distribution that can be associated with metabolic abnormalities, including dyslipidemia and insulin resistance. Facial wasting or lipoatrophy describes loss of subcutaneous fat around the cheeks. Studies have shown that that lipoatrophy was associated with higher rates depression and stigmatization in this population.
  
Sculptra was Food and Drug Administration (FDA) approved in 2004 for restoration and or correction of the signs of facial fat loss in immune compromised patients. Sculptra is an injectable poly-L-lactic acid (PLLA), a biodegradable, biocompatible, immunologically inert substance, that works as a dermal filler. 

Use of PLLA for immunodeficiency-associated facial lipoatrophy has been supported by several trials and observational studies that have demonstrated improvement in patient appearance and cutaneous thickness as well as overall safety.

Based on above findings, dermal Injections for treatment of facial lipodystrophy - outpatient procedure is considered 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 dermal Injections for treatment of facial lipodystrophy - outpatient procedure is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment: Consumer Directed Personal Assistance Services 
for a Total of 56 Hours Per Week
The insurer denied: Consumer Directed Personal Assistance Services for a Total of 56 Hours Per Week
The denial is upheld

The patient is an adult male. His conditions include multiple sclerosis and visual impairment. Denial of Consumer Directed Personal Assistance Services for a total of 56 hours per week is being appealed. The health plan approved 11 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed 6 months ago shows minimally impaired cognition and functional status: total dependence with meal preparation; extensive assistance with housework, shopping, and dressing; limited assistance with managing finances; supervision with managing medications, stairs, transportation, bathing; and independent with phone use, personal hygiene, walking, toileting, locomotion, bed mobility and eating. He has infrequent urinary incontinence. A letter from the patient's provider notes the patient's MS (multiple sclerosis) has been worsening. He is more unsteady and has cognitive problems. He requires more assistance with ADLs (activities of daily living) as well as supervision at home.

The requested Consumer Directed Personal Assistance Services for a Total of 56 Hours Per Week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of Consumer Directed Personal Assistance Services for a total of 56 hours per week is being appealed. The health plan approved 11 hours per week.
This patient has multiple sclerosis. Uniform Assessment System (UAS) evaluation completed 6 months ago shows he requires assistance with meal preparation, housework, shopping, dressing, and with managing finances. The appeal statement notes that the patient's gait is more unsteady, and he requires more assistance with ADLs (activities of daily living) as well as supervision at home. The information provided does to support that the patient's needs for assistance with ADLs (activities of daily living) cannot be met with the currently approved assistance of 11 hour per week. Consumer directed personal assistance services is not indicated supervision. The requested increase in assistance to 56 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Constipation

Treatment: Linzess 145 microgram (mcg)

The insurer denied coverage for Linzess 145 mcg

The denial is overturned.

The patient has chronic constipation. Her physician wrote that she had failed Miralax and Dulcolax. She also tried and could not tolerate lubiprostone. She had previously been on Linzess but stopped it during her pregnancy. 

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacologic therapy. There are several recommended treatments including linaclotide (Linzess), plecanatide, lubiprostone, and prucalopride. In 2 large phase 3 trials, linaclotide treated patients had significantly higher rates of spontaneous bowel movements as compared to placebo. 

The insurance company has denied Linzess stating that there are formulary alternatives of Lactulose and lubiporstone. However, the patient has already failed Lactulose, Miralax, Dulcolax, and Lubiprostone. Linaclotide is approved by the Food and Drug Administration (FDA) for treatment of chronic constipation. Since she has failed the formulary alternatives, it would be appropriate to restart the Linzess. Linzess is a medically necessary treatment. 

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 Linzess 145 mcg capsule is substantiated.