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

Diagnosis: Complex regional pain syndrome
Treatment: Pain management (sympathetic nerve block - 64520 x 1)
The insurer denied the sympathetic nerve block.
The denial has been upheld as not medically necessary.

The patient is a male that presented with a history of lumbar pain. Exam of the lumbosacral spine revealed paraspinal muscle tenderness bilaterally, and facet loading positive bilaterally. Diagnoses include myalgia of the auxiliary muscles of the head and neck, cervical radiculopathy, complex regional pain syndrome (CRPS), coccydynia, lumbar spondylosis, and lumbar reticulitis.

Based on the documentation provided, the requested ganglion impar block is not considered medically necessary at this time. Though the patient has a history of chronic pain, there was lack of documentation to support the patient's diagnosis of CRPS for treatment. The patient does not meet Budapest criteria including:

New International Association for the Study of Pain (IASP) diagnostic criteria for complex regional pain syndrome ("Budapest criteria") (A-D must apply).

A) The patient has continuing pain which is disproportionate to any inciting event B) The patient reports at least one symptom in 3 or more of the categories C) The patient displays at least one sign in 2 or more of the categories D) No other diagnosis can better explain the signs and symptoms.

Category:
1) Sensory: Allodynia (to light touch/brush stroke and/or temperature sensation and/or deep somatic pressure and/or joint movement), and/or hyperalgesia (to pinprick); Reported hyperesthesia also qualifies as a symptom 2) Vasomotor: Temperature asymmetry and/or skin color changes and/or skin color asymmetry 3) Sudomotor/oedema: Oedema and/or sweating changes and/or sweating asymmetry 4) Motor/trophic: Decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair/nail/skin).       

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal stress myocardial perfusion imaging (MPI)
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial has been upheld as not medically necessary.

This male patient was hospitalized for elective left heart catheterization (LHC). He had an abnormal stress myocardial perfusion imaging (MPI) and an ejection fraction (EF) of 32 percent. He underwent successful percutaneous coronary intervention (PCI) with stent to the left anterior descending (LAD) on the same day. There were no procedural complications, slight oozing from the groin was managed with additional pressure and he was discharged to home the next day. This is an appeal of the denied claim for the requested acute inpatient hospital stay.

In this particular case, the patient underwent elective, successful and uncomplicated cardiac catheterization with coronary angiography and PCI on the same day. The information provided does not support the medical necessity for admission after his coronary intervention. This procedure is routinely performed now in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like acute myocardial infarct (AMI), contrast nephropathy, acutely decompensated congestive heart failure (CHF), life-threatening cardiac arrhythmia, procedural complications, or other medical instability or acute care needs that would require acute inpatient management. Therefore, the proposed treatment is not medically necessary.       

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

In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay past the observation period. The care the patient received, including elective cardiac catheterization with successful PCI like in this case, is routinely provided safely and effectively at a lower level of care, such as in the hospital's ambulatory setting with observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This case involves an adult female under review for inpatient hospital stay. Emergency department note reported the patient had complaints of nausea, vomiting, chills, and abdominal pain for the last few weeks. The patient had a history of pancreatitis as well as chronic abdominal pain, fibromyalgia, bipolar disorder, and hypertension. Physical exam noted generalized tenderness of the abdomen with no guarding or rebound tenderness. Electrocardiogram (EKG) noted sinus tachycardia with nonspecific ST-T changes and prolonged QTc. The patient was treated with intravenous (IV) droperidol and intravenous (IV) fluid. There was difficulty gaining IV access for computed tomography angiogram (CTA). Treatment plan included diagnostic work-up.

History and physical reported there were evidence of pancolitis on CT scan of the abdomen and pelvis. The patient was recommended for gastrointestinal (GI) consult and treatment of infectious colitis. 

Progress note reported chest pain had resolved and there were no acute overnight events. The patient continued to have unchanged diffuse abdominal pain. It was noted the patient was hemodynamically stable and afebrile. Treatment plan was for CT angiogram. 

CT angiogram of the chest was negative for pulmonary embolism. The patient was scheduled for Esophagogastroduodenoscopy (EGD) and colonoscopy but did not complete bowel prep given nausea. 

Progress note reported the patient had unchanged diffuse lower abdominal pain. The patient had undergone EGD/colonoscopy with gastric fold thickening. Biopsy results were pending. 

Progress note reported the patient stated she had an unwitnessed fall that morning due to dizziness. The patient reported hitting the back of her head but denied loss of consciousness. There was slight improvement in the diffuse lower abdominal pain. The patient was recommended for continued monitoring with consideration for computed tomography (CT) of the head if no improvement. 

Milliman Care Guidelines (MCG) recommends inpatient level of care for patients with acute severe ulcerative colitis and/or abdominal pain that persists despite observation care. In this case, the patient had complaints of frequent non-bloody diarrhea, and tachycardia. There was also persistent abdominal pain despite medication management. The patient had CT evidence of acute pancolitis and underwent EGD and colonoscopy during the inpatient stay. The severity and duration of the patient's condition would warrant inpatient admission. 

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 admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: Procedure code 43284, LINX Reflux Management System

The insurer denied coverage for procedure code 43284, LINX Reflux Management System

The denial is overturned


The patient has persistent gastroesophageal reflux disease (GERD) that has not been controlled by proton pump inhibitor (PPI) therapy. A workup was done including upper gastrointestinal (GI) series, endoscopy, and Bravo pH (acid or alkaline) testing. The DeMeester score was 22.5. The upper GI series revealed moderate to large gastroesophageal reflux extending to the upper esophagus. His physician has advised that he is a good candidate for the LINX procedure. 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management System in March 2017. With regards to safety, the conclusion was that long-term follow-up supports the Food and Drug Administration (FDA) conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following LINX. The long-term follow-up data demonstrates that the LINX Reflux Management System is effective in the management of GERD. 

The Annals of Surgery 2019 Aug 270(2):302-308 has an article titled "Objective Evidence of Reflux Control After Magnetic Sphincter Augmentation: One Year Results From a Post Approval Study." The conclusion was that both safety and effectiveness of magnetic sphincter augmentation has been demonstrated outside of an investigational setting to further confirm the procedure as treatment for GERD. 

The scientific literature supports the use of the LINX system as a treatment for GERD. The 2019 study in the Annals of Surgery confirms the long term safety and efficacy of the procedure. 

The LINX system has been approved by the FDA. 

The patient is a good candidate since he has chronic GERD and has had continued symptoms on long term PPI therapy. There are multiple options for treating GERD, but the LINX system has been shown to be both effective and safe. The procedure has been shown to be beneficial for chronic GERD. 

In summary, the denial of procedure code 43284, LINX Reflux Management System and coverage for the requested service/treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental decay
Treatment: White glass with metal crown for tooth 30 and ready-made post for filling for a crown for tooth 30
The insurer denied coverage for white glass with metal crown for tooth 30 and ready-made post for filling for a crown for tooth 30
The denial is overturned.

Based on the submitted documentation which includes copies of pretreatment, mid and post treatment periapical radiographs, narrative letter from the patient and insurer correspondence and coverage booklet, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was recommended and completed on tooth #30 with additional recommendation of full coverage crown restoration on this tooth. 

Upon review of radiographs, it supports the recommended treatment. Review of radiographs indicates a completed endodontic therapy #30. There is ample coronal structure remaining after the endodontic therapy. This tooth will have adequate residual coronal structure for support of crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of a post and core and crown on an endodontically treated tooth which would have an excellent long-term prognosis with the recommended treatment.

White glass with metal crown for tooth 30 and readymade post for filling for a crown for tooth 30 is considered medically necessary for this patient.

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 white glass with metal crown for tooth 30 and ready-made post for filling for a crown for tooth 30 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Dental Issues
Treatment: Dental/Orthodontic Procedure/Periodontal Maintenance
The health plan denied the requested Periodontal Maintenance as not medically necessary. 
The health plan's determination is overturned.

The patient is a male who presented to the office for the treatment of his periodontal disease. Provided for review are a letter from the patient, bitewing radiographs, periodontal indices, letter of consultation multiple pages of financial ledgers, American Dental Association (ADA) claim forms, multiple pages of explanation of benefits, and health plan language. In question is the medical necessity of the treatment of scaling and root planning upper and lower. Previous denials have been on the basis that benefits have already been allowed and that further benefits can only be allowed if there is evidence of recurrent disease.
At issue is the medical necessity for the requested health service/treatment of periodontal maintenance.

I overturn, in whole, the health plan's determination of medical necessity.

The patient currently has the diagnosis of active periodontal disease with deep probing's and a history of attachment loss. For patients who have evidence of attachment loss in the presence of active inflammation and with concomitant pocketing, scaling and root planning is the therapy of choice. Hence, the treatment of scaling and root planning for upper and lower is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Nasal valve collapse.
Treatment: VivAer Procedure.
The insurer denied VivAer Procedure.
The determination is overturned.

This is a female patient with a history of turbinate hypertrophy, nasal congestion, and stuffiness. The patient has had symptoms for several years that failed treatment with oral antihistamines, nasal steroids, oral steroids, and oral antibiotics. Because of the nasal valve collapse, the patient's symptoms improved with a Cottle maneuver. On examination, there was stringy mucous present bilaterally and nasal valve collapse present bilaterally. The intra-nasal nasal septum was midline and the mucosa was normal (inferior turbinates appearance was normal).
Because of the symptoms, the patient requested to be treated with a surgical procedure with temperature-controlled radiofrequency of the nasal valves-VivAer (radiofrequency cartilage remodeling). At issue is whether the VivAer Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The VivAer Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient does meet the criteria for correction of the nasal valve collapse with the VivAer device. This procedure involves using radiofrequency to scar up the lateral nasal cartilages to prevent the medial collapse. The current literature shows that the VivAer device was able to perform some "remodeling of the nasal valve that may have a profound effect on perceived nasal obstruction, despite little effect on nasal resistance."
The requested procedure is likely to be more beneficial for the patient's symptoms than any other further treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Nasal valve collapse.
Treatment: VivAer Procedure.
The insurer denied VivAer Procedure.
The determination is overturned.

This is a female patient with a history of nasal congestion/obstruction for several years with symptoms improved with a modified Cottle maneuver. Based on the submitted medical records, she has received multiple treatments including intranasal corticosteroids, intranasal saline rinses, oral corticosteroids, oral antihistamines, oral decongestants, balloon sinuplasty for chronic sinusitis, and oral antibiotics in the past without sustained improvement in symptoms. The clinical exam was consistent with nasal valve collapse. The patient's otolaryngologist is requesting the VivAer procedure for repair of nasal valve collapse. At issue is whether the VivAer Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The procedure/treatment with VivAer is likely to be more beneficial for this patient since she has received standard treatments to date without sufficient improvement in symptoms. The patient has received a thorough workup including physical examination and appropriate standard medical treatment to treatment nasal congestion/obstruction. The patient has undergone maximal medical therapy including undergoing treatment with intranasal corticosteroids, intranasal saline rinses, oral antibiotics, oral corticosteroids, oral decongestants, oral antihistamines, and balloon sinuplasty without sufficient improvement in symptoms. Clinical examination confirmed that the patient had nasal valve collapse contributing to the patient's symptoms of nasal congestion. The ViVaer is used to coagulate soft tissue in the nasal airway to strategically treat nasal airway obstruction by shrinking submucosal tissue and is an appropriate next step in treatment for this patient. VivAer received Food and Drug Administration (FDA) approval for this indication in 2017. There are sufficient clinical trials and peer reviewed literature to support the benefits of the procedure in appropriate patients.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Nasal valve collapse
Treatment: VivAer Procedure
The insurer denied VivAer Procedure
The determination is upheld.

This is a female patient with a history of nasal obstruction and congestion. Medical management has included nasal steroids, oral antihistamines and oral antibiotics. Her exam revealed nasal valve collapse and turbinate hypertrophy. VivAer procedure was denied by the health plan. At issue is whether the VivAer Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The VivAer 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 Vivaer procedure has not been shown in well-designed studies to be as effective as standard rhinoplasty techniques for the treatment of nasal valve collapse. There are a lack of well-designed studies in the peer reviewed literature demonstrating long term efficacy of this treatment for nasal valve collapse. The current studies are heterogenous and not well controlled. The longest study to date (2) had only 24 patients complete the study in 2 years a less than 32 percent (%) non-significant improvement rate, was funded by the device manufacturer, and did not control for medication usage.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, Charcot joint (right ankle/foot) and depression
Treatment: Continued skilled nursing stay
The insurer denied coverage for continued skilled nursing stay.
The denial is upheld.

The patient is an adult with chronic medical problems including diabetes, Charcot joint (right ankle/foot), and depression. The patient was transferred to the skilled nursing facility (SNF) after foot surgery and external fixator. Under review is the medical necessity for continued skilled nursing stay.

The patient was initially an appropriate candidate for the SNF subacute rehabilitation level of care [1, 2, 3] for the time period under review. The patient had functional impairments amenable to (subacute) rehabilitation therapy. The physical and occupational therapy notes document significant functional improvement. According to the physical therapy notes, the patient had good (dynamic) standing balance, was independent with transfers and could ascend/descend 7 steps. The occupational therapy notes indicated the patient was capable of performing hygiene/grooming, toileting, and dressing activities. The patient could have been safely discharged to a lower level of care (such as home with outpatient physical therapy services). There were also no additional acute medical or complicated nursing issues to support continued skilled nursing stay.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued skilled nursing stay was not medically necessary.

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

The medical necessity for the continued skilled nursing stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient is an adult who presented 4 days after vaginal delivery to Montefiore Medical Center Emergency Department (ED) due to hypertension, headaches, and abdominal pain. The patient had elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT). In addition, pelvic examination was suggestive of endometritis.

The patient was admitted and received magnesium sulfate for seizure prophylaxis. She was started on Nifedipine with improved blood pressure (BP) control. She was started on intravenous (IV) antibiotics for endometritis. 

This patient presented 4 days  after delivery with elevated blood pressure and liver function tests (2x the upper limit of normal). Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery. The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:

The patient had signs of end-organ dysfunction as she had elevated serum transaminases to twice normal concentration).In addition, the patient had signs and symptoms of endometritis. Treatment is indicated for relief of symptoms and to prevent sequelae, such as peritonitis, salpingitis, oophoritis, phlegmon or abscess, and septic pelvic thrombophlebitis. In summary, admission was medically necessary for magnesium sulfate prophylaxis as well as for IV antibiotics to manage postpartum endometritis and prevent serious sequelae. 

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decay/Fracture(s).
Treatment: Amalgam or Resin-Based Composite Filling 
(Restoration, Tooth Numbers 12, 15, and 16).
The insurer denied: Amalgam or Resin-Based Composite Filling 
(Restoration, Tooth Numbers 12, 15, and 16).
The denial is upheld.

The patient is an adult male requesting benefits for fillings on teeth numbers 12, 15 and 16. The prior denial was due to no evidence of new or recurrent decay and or fractures in any of the teeth.

The three fillings are not medically necessary.

The x-rays presented do not show any new or recurrent decay present in these teeth. No fractures are seen either. The black and white photos presented are of extremely poor quality and do not show anything of value. It is impossible to see the teeth and whether the photos are pre-operative or post- operative. Color photos may have helped to see any decay and/or fractures, but they were not supplied. Without seeing decay and/or fractures, there is no need for treatment and no medical necessity.