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

Diagnosis: Dyshidrotic eczema

Treatment: Dupixent Syn (syringe) 300

The insurer denied coverage for Dupixent Syn 300

The denial is overturned.

 
The patient has a diagnosis of dyshidrotic eczema. The patient has failed tacrolimus ointment, halobetasol, and fluocinonide ointment, as well as over the counter (OTC) ammonium lactate cream and in office narrow band - ultraviolet B (NB-UVB) therapy. The request is for Dupixent.  

Based on the submitted documentation, the use of Dupixent is within the standard of care.  The patient has failed therapy with topical steroids as well as non-steroidal tacrolimus.  A trial of light therapy did not result in documented significant improvement.  The patient requires systemic therapy.  Although Dupixent is approved for atopic dermatitis, there is significant overlap with dyshidrotic eczema which should result in improvement of the patient's hand and foot dermatitis with minimal risk of toxicity compared to other systemic options which also are not Food and Drug Administration (FDA) approved.  As such, the decision is reversed and Dupixent is approved for use at the medical discretion of the physician based on the standard of care and the provided medical documentation.   

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 Dupixent Syn 300 services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angioedema/Allergy

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld 

This patient presented to the hospital with complaints of an allergic reaction, with tongue swelling and rash. The patient has had these in the past. On physical examination, there was right tongue swelling without stridor, drooling, respiratory distress, or dysphonia. The vital signs were normal. The patient was treated with epinephrine, Benadryl, Pepcid, Solumedrol and Intravenous Fluids (IVF) and admitted for poor social situation and angioedema/allergy/anaphylaxis. 

An electrocardiogram (EKG) showed no acute changes. The resident examination also noted some face and hand swelling, with some urticaria. No otolaryngology or anesthesiology consultation was obtained. The patient signed out against medical advice. The patient's condition, however, did not warrant hospitalization beyond observation care.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure 
The insurer denied: Intraosseous Basivertebral Nerve Ablation Procedure as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with low back pain. Prior treatments included activity modification, acupuncture, home exercises, injections, medications, as well as physical therapy. His pain impacts activities of daily living. Pain ranges from 3 out of 10 through 7 out of 10. A magnetic resonance imaging (MRI) demonstrated Modic type I and 2 changes at (lumbar) L4-5 and (lumbar-sacral) L5-S1. There is a request for Intraosseous Basivertebral Nerve Ablation Procedure.

I uphold, the health plan's determination, in whole.

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

Diagnosis: Left axillary vein deep vein thrombosis. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is overturned. 

This patient is an adult who presented to the Emergency Department (ED) for chest pain and left arm pain. A left upper extremity (LUE) ultrasound was performed that revealed an acute left axillary vein deep vein thrombosis (DVT) with physical findings and diminished pulses at the wrists. Vascular surgery was consulted and recommended anticoagulation along with computed tomography imaging. The patient was admitted to vascular for further management of an acute left axillary vein DVT. The patient received intravenous (IV) Heparin. 

The patient underwent a left upper extremity (LUE) venogram and venoplasty for a high-grade stenosis. Post-operative management included pain control, IV anticoagulation, and IV fluids. Hematology was also consulted. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Most upper extremity DVTs are of little clinical consequence; however, in this case, there were physical findings that threatened circulation in the left arm and surgical intervention was appropriate. 

The hospital admission is considered medically necessary. The patient presented to the Emergency Department (ED) for chest pain and left arm pain. She was diagnosed with left axillary vein DVT with physical findings and diminished pulses at the wrists. Initial anti-coagulation with heparin was appropriate as the most flexible anticoagulation method allowing surgery as soon as possible. However, it required time for effectiveness and would somewhat delay surgery. Therefore, the hospital admission is considered medically necessary. 

"The treatment of upper extremity DVTs depends on the clinical presentation. The majority of patients present with limb swelling in the setting of central venous catheterization. The American College of Chest Physicians recommends that the clinician first determine the necessity of the line. If required (e.g., total peripheral nutrition), it should remain in place, and the patient should be started on anticoagulation therapy. If the line is not needed, it should be removed but only after the completion of 3 to 5 days of anticoagulation therapy. In the hospital, patients can be bridged to warfarin with unfractionated heparin. Patients should continue on warfarin for 3 to 6 months after diagnosis. The role of novel oral anticoagulant agents (e.g., dabigatran) is under current investigation. Still, recent data from the Swedish national anticoagulation registry (National Quality Registry for Atrial Fibrillation and Anticoagulation [AuriculA]) suggests that these drugs can be used to treat upper extremity DVT with acceptable efficacy and safety." (Grigorian & Nahmias, 2022) 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. 

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied inpatient hospital stay.  
The denial is upheld.

The patient is a female, who presented to the emergency department (ED) with upper abdominal pain, nausea and vomiting of one-day duration. At the time of presentation the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was normal at 7.6 thousand (K). The complete metabolic panel identified normal liver enzymes and bilirubin. Abdominal ultrasound showed a distended gallbladder. She was admitted to the hospital with the diagnosis of biliary colic/cholecystitis.

The patient was evaluated with surgery consultation. The patient underwent laparoscopic cholecystectomy. The operation was performed without complication with findings of hydrops of the gallbladder. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up.

The subject under review is the medical necessity for the inpatient hospital stay.

An inpatient hospital stay was not medically necessary in this case. This patient presented to the hospital with abdominal pain. She was determined to have symptomatic cholelithiasis/biliary colic. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established. The patient admitted to the hospital. She underwent surgery to remove the gallbladder. The patient responded favorably to treatment and was stable for discharge from the hospital with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, surgical assessment and monitoring, laparoscopic cholecystectomy as performed, provision of intravenous (IV) antibiotics and fluid, and overnight care. Milliman Care Guidelines (MCG) 26th ed Cholecystectomy by Laparoscopy criteria is not met in this case to warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Memory Loss
Treatment: Consumer Directed Personal Assistance
The insurer denied: Consumer Directed Personal Assistance
The denial is: Upheld

This is a case review for a male with medical history notable for memory loss and imbalance. The patient and his care team requested Consumer Directed Personal Assistance to assist with "light housekeeping tasks, reminding to take meds, driving" and this request was denied by the health plan. This denial is the subject under review.

The requested treatment of Consumer Directed Personal Assistance has not been demonstrated to be medically necessary for this patient.
The patient has some functional limitations in instrumental activities of daily living (IADL's) secondary to dizziness and falls. He has been receiving informal support to assist with these functions. He has not undergone a complete medical workup to determine the etiology of these symptoms. Continued workup and consultation with his physicians and specialists should yield an appropriate diagnosis and treatment plan. In the interim, there is not any evidence of unmet personal care needs which would make Consumer Directed Personal Assistance Services (CDPAS) medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented for a laparoscopic cholecystectomy. The patient had a previously attempted cholecystectomy which was aborted. The surgery was difficult and the gallbladder had to be opened to remove the stone, The cystic duct was identified from the inside and the gallbladder was removed. The cystic cut was sutured to avoid injury to the hepatic duct. A 19 French Jackson-Pratt (JP) drain was placed and brought out through a port. The patient was admitted overnight. At issue is the medical necessity of an inpatient stay.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission.

While it appears that the gallbladder was difficult to remove, inpatient services were not utilized. The patient was admitted overnight. The next morning the patient was doing well and was discharged home. The patient did not demonstrate signs of systemic infection in association with the cholecystitis. The patient also did not demonstrate significant concern for cholangitis. The patient did not demonstrate hemodynamic instability. The patient did not demonstrate severe or persistent pain that would require high dose administration and monitoring. The patient did not demonstrate significant vomiting. The patient did not have signs of sepsis or bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level care. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visits
The insurer denied braces and monthly visits.
The denial is overturned.

The patient is an adolescent male with a Class I malocclusion. He has a narrow upper arch with moderate crowding. He has an anterior tooth in cross-bite. The health plan denied coverage of the request for braces due to a handicapping index score of 20.

The braces and monthly visits are medically necessary.

The patient's upper jaw is too narrow and therefore tooth # (number) 6, the upper right permanent canine, cannot erupt into its proper position. Without this tooth being in its proper place, there can be no "canine guidance" on the right side. This means that during the chewing cycle, instead of the lower teeth gliding along the upper teeth harmoniously, there will be no order to the chewing cycle. The teeth on the right side will bang into each other in a traumatic way. Over time, this will cause loosening of teeth or fractures. TMJ (temporomandibular jaw) issues could develop over time also. The only correction of this is with orthodontic treatment. This case has medical necessity to correct the patient's dentition. The monthly visits are needed to make sure everything progresses smoothly in an orderly fashion.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease. 
Treatment: Personal care worker (PCW) 12 hours x 2 per day (split shift) Sunday - Saturday. 

The insurer denied coverage for PCW 12 hours x 2 per day (split shift) Sunday - Saturday. 

The denial is overturned. 

This is an elderly patient with Parkinson's disease who lives alone in an apartment. She currently has a PCW 12 hours/day, 7 days/week totaling 84 hours. The request is for PCW 12 hours x 2 per day (split shift) Sunday - Saturday totaling 168 hours per week.  

The recent Uniform Assessment System (UAS) report was reviewed. The patient cognition is described as minimally impaired. She requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for personal hygiene, upper body dressing, ambulation, and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and eating. She has a shuffling gait, cardiac arrhythmia and episodes of dizziness, resulting in falls. This patient's treating physician submitted a letter indicating her condition is deteriorating, requires bed repositioning and frequently falls, which more recently required hospitalization. The combination of the patient impairments, deteriorating medical conditions and multiple falls resulting in hospitalizations support the medical necessity of the requested PCW 12 hours x 2 per day (split shift) Sunday - Saturday. The patient's health and safety can be appropriately provided and maintained by the requested increase PCW 12 hours x 2 per day (split shift) Sunday - Saturday, totaling 168 hours per week. 
  
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, boards and associations. All decisions are evidence-based.  

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. 

The insurer's denial of coverage for the personal care worker (PCW) 12 hours x 2 per day (split shift) Sunday - Saturday is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient has a history of chronic obstructive pulmonary disease (COPD) and asthma with a frequent exacerbation history. The presenting complaints were dyspnea. The patient took nebulizer treatments at home without improvement in her symptoms. The physical exam was notable for good air movement, scattered wheezes were auscultated, she had no respiratory distress, and was speaking in full sentences. Shortly after arrival to the emergency department (ED), the patient developed hives on her arms. Lab results were notable for hyperglycemia. Radiology was notable for a chest x-ray without evidence of pulmonary disease. In the ED she was treated with intravenous (IV) steroids, diphenhydramine, and famotidine. Nursing documentation a few hours after the ED provider's assessment described a patient breathing comfortably with an oxygen saturation 98 percent (%) on room air. She was admitted to the inpatient medicine service where steroid and nebulizer therapy was continued.

An inpatient stay was not medically necessary. The patient presented with dyspnea consistent with prior asthma exacerbations. On arrival to the emergency department, normal vital signs were documented with no evidence of hypoxia, tachypnea, or tachycardia. The patient's physical exam described the absence of respiratory distress, good air movement, and an overall comfortable appearance. A followup assessment by a nurse a few hours later described a comfortable-appearing patient again without hypoxia. The patient's continued subjective improvement was documented. With a good trajectory of her presenting illness, a lower level of care would have been appropriate to monitor her continued response to the treatment plan initiated in the ED, watch for recrudescence of her symptoms, and ensure adequate outpatient followup. Although she developed hives in the emergency department, this condition was described as a recurrent outpatient problem and would also have benefited from a lower level of care to ensure improvement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhinovirus and parainfluenza infections

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

The patient is a young adult pregnant female with a history of bronchospasm who presented to the emergency room (ER) with complaints of a 2-day history of shortness of breath (SOB). The patient tested positive for rhinovirus and parainfluenza virus. The patient was admitted to Labor and Delivery (L&D) for care. The patient was given solumedrol and albuterol. Pulmonology was consulted and the patient was placed on 2 liters (L) of oxygen via nasal cannula (NC). A chest x-ray (CXR) revealed no significant findings. Nebulizer treatments were given every 6 hours (Q6H) and Solumedrol was given every 8 hours (Q8H). Pulmicort was given as ordered. The patient's condition improved after treatment, and she was discharged. 

As per standard of care, hospitalization is warranted for patients with significant dehydration and for severely ill patients, especially those with respiratory distress, hypoxemia, impaired cardiopulmonary function, or altered mental status. For patients at risk for complications but without these findings, admission for observation may be warranted. This patient has a history of bronchospasm and is therefore at higher risk for complications. Pregnant patients with viral respiratory infections are more likely to be hospitalized and admitted to an intensive care unit and have a higher mortality compared with the general population. 

This patient had rhinovirus and parainfluenza infections with concern about impaired cardiopulmonary function. In addition, there was evidence of deterioration in her respiratory status necessitating oxygen supplementation and high dose steroid treatments. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

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

Diagnosis: Pilonidal cyst.

Treatment: outpatient procedure (17999) x 12 ambulatory surgery.

The insurer denied coverage for outpatient procedure (17999) x 12 ambulatory surgery.

The denial is overturned.

The patient is an adolescent male with recurrent pilonidal cyst. The patient has had two surgical procedures to remove the pilonidal cyst.  Both surgical procedures were complicated by poor wound closure with non-healing areas. The second surgical procedure required a flap closure. The patient is followed by a colorectal surgeon as well as plastic surgery and dermatology. The medical recommendation was for laser hair removal to treat, accelerate wound healing and minimize risk of recurrence. The request is for evaluation of CPT code 17999 for laser hair destruction.  

Based on the submitted documentation and the standard of care, the use of laser hair destruction is considered medically necessary in the treatment of the patient's pilonidal cyst. The patient has had multiple surgical failures with surgical complications with standard surgical procedure. The use of laser hair destruction at the site of the pilonidal cyst is within the standard of care for improving healing and reducing the risk of recurrence of the pilonidal cyst. Ghnnam and Hafez conclude, "We advocate the use of laser epilation after surgery for pilonidal sinus as it decreases the chance of recurrence."  The use of laser hair removal as an adjuvant therapy to decrease recurrence is approved based on the standard of care. 

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 outpatient procedure (17999) x 12 ambulatory surgery services is substantiated.