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

Diagnosis:  Left proximal femoral lesion.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

This is a female status post (s/p) open biopsy for left proximal femoral lesion.  The patient did not have malignancy (diagnosis was bone cyst versus giant cell tumor).  She underwent surgical management of curettage, cement and internal fixation.  Her post-surgical course was non-complicated.  She was discharged.

No, the proposed inpatient admission was not medically necessary.

The medical record demonstrated surgical management of lesion and a non-complicated post-operative course.  There were no problems with the patient's wound.  Her vital signs were stable.  The hematocrit drop did not require transfusion.  There was no need for a drain.  Her pain was adequately managed.  She was able to make satisfactory progress with physical therapy (PT).  She did not require management of an underlying medical problem.  Thus, there were no extenuating circumstances to substantiate the inpatient admission and length of stay.  There were no signs of pain, fever, infection or bleeding.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple myeloma, musculoskeletal pain, gait ataxia, unintended weight loss and fatigue.
Treatment: Increase Personal Care Aide (PCA) Level 2: 10 Hours Per Day -7 Days Per Week For a Total Of 70 Hours Per Week.
The insurer denied the Increase Personal Care Aide (PCA) Level 2: 10 Hours Per Day -7 Days Per Week For a Total Of 70 Hours Per Week. 
The denial is overturned. 

The patient is a female with a history of multiple myeloma and associated musculoskeletal pain, gait ataxia, unintended weight loss and fatigue. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 70 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Increase of Personal Care Aide services Level 2 to 10 hours per day, 7 days per week, for a total of 70 hours per week is deemed medically necessary. 

This is a female with a history of Multiple myeloma and associated musculoskeletal pain, gait ataxia, unintended weight loss and fatigue. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to worsening musculoskeletal pain, decreased mobility, worsening gait ataxia and fatigue; the patient's functionality and ability to perform ADLs (activities of daily living) has progressively declined. Hence, the currently approved plan of 45.6 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 70 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

This is a male patient with a history of alcohol abuse, subdural hematoma, and chronic pain. The patient was brought to the hospital by Emergency Medical Services (EMS) with complaints of seizure-like activity associated with nausea, and non-bilious, non-bloody vomiting. In the Emergency Room (ER), the patient was ill-appearing, and appeared weak and dehydrated. The patient's vital signs were: blood pressure 102/56, heart rate 90, temperature 98, and respiratory rate 18. In the ER, the patient had persistent low pulse oximetry readings that ranged from 86% to 89% despite oxygen supplementation, 10 liters of oxygen via facemask. The patient appeared dusky and exhibited signs of central cyanosis. The patient was transferred to the critical care area of the ER due to the unexplainable decrease in his oxygen saturation. The patient's arterial blood gas revealed a pH of 7.4, partial pressure of carbon dioxide 35, partial pressure of oxygen 146, and bicarbonate 21. The patient's carboxyhemoglobin level was 1.5 and his methemoglobin level 26%. The patient's urine toxicology was positive for cocaine. The patient admitted to drinking alcohol and smoking marijuana on the day of admission.  The patient was admitted for methemoglobinemia from unknown cause. The patient was treated in the Intensive Care Unit (ICU) with methylene blue administration. The patient left against medical advice (AMA) the day after admission.

Based on the review of the medical record and literature, it was medically necessary to admit this patient with a methemoglobin level of 26%. As per Ponce Rios et al. (2019), methemoglobinemia should be treated aggressively, especially if methemoglobin levels are above 20% or if the patient is symptomatic. Similarly, D'sa et al. (2014)'s study showed that "of the 824 patients admitted with poisoning (and symptomatic methemoglobin), 5 patients with methemoglobin concentration greater than or equal to 49% were included...and all the] patients were managed in the intensive care unit."

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

The carrier's denial of coverage for the inpatient hospital admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait ataxia, chronic obstructive pulmonary disease, poor visual acuity.
Treatment: Personal Care Services 24 hours/day, 7 days/week (live-in), for a total of 91 hours/week.
The insurer denied the Personal Care Services 24 hours/day, 7 days/week (live-in), for a total of 91 hours/week.
The denial is overturned. 

The patient is a female with a history of cognitive decline, gait ataxia, COPD (chronic obstructive pulmonary disease) on supplemental oxygen, poor visual acuity and depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 24 hours/day, 7 days/week (live-in) Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 24 hours/day, 7 days/week (live-in) Personal Assistance Services is deemed medically necessary. 

This is a female with a history of cognitive decline, gait ataxia, chronic obstructive pulmonary disease (COPD) on supplemental oxygen, poor visual acuity and depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent correspondence from her physician indicates that due to worsening cognitive decline, gait ataxia, dyspnea, fatigue and depression, the currently approved plan of 84 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 24 hours/day, 7 days/week (live-in) Personal Assistance Services is deemed medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: High Blood Pressure. 
Treatment: Formulary exception for Coreg CR (Carvedilol Phosphate Extended-Release) 40 mg (milligrams) CAP. 

The insurer denied the Formulary exception for Coreg CR (Carvedilol Phosphate Extended Release) 40 mg (milligrams) CAP. 
The denial is upheld. 

The patient is a male with a history of hypertension. Carvedilol CR (Carvedilol Phosphate Extended-Release) 40 mg (milligrams), has been used as a part of his regimen for blood pressure control. Continuation of Carvedilol CR (Carvedilol Phosphate Extended-Release) 40 mg (milligrams) has been requested. Coverage was denied, as the medication is non-formulary, and there is no documented failure of preferred alternatives. 

No, the health plan should not cover the Formulary exception for Coreg CR (Carvedilol Phosphate Extended-Release) 40 mg (milligrams). 

The patient has a history of hypertension, which has been controlled on the current regimen of amlodipine, olmesartan and carvedilol CR (Carvedilol Phosphate Extended-Release). There is no history of intolerance or failure of immediate release carvedilol or other formulary alternatives listed. The formulary alternatives (carvedilol [immediate release] tablets, metoprolol succinate extended-release tablets, and propranolol extended-release capsules) would be expected to be as efficacious as Coreg CR (Carvedilol Phosphate Extended-Release) 40 mg (milligrams) for the patient's condition (hypertension). The patient does not have any documented contraindication to the formulary alternatives. Therefore, given the above, the medical necessity of the requested non-formulary medication could not be established.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic pain. 
Treatment: Outpatient Procedures (64418 x5, 64400 x5, 64405 x5, 64450 x5, 20553 x5). 

The insurer denied coverage for Outpatient Procedures (64418 x5, 64400 x5, 64405 x5, 64450 x5, 20553 x5). 

The denial is modified. 

This is a female patient with a medical history of systemic lupus erythematosus (SLE) and chronic migraine headaches. The patient has chronic pain involving her head and neck. A neurology note states the patient gets trigger point injections (TPI) every 4 weeks for this pain and she benefits from these injections. Office notes describe the plan as "TPI/B12 today" and document trigger point injections of >3 muscles (bilateral trapezius, CPS, rhomboids). Injections for suprascapular, greater and lesser occipital nerve block were also performed. A pre-injection pain rating of 6 is recorded but no post-injection pain rating is reported. 

There is some evidence supporting the benefit of TPI for headaches. As noted by Robbins et al "In a study surveying the use of PNBs [peripheral nerve blockers] and TPIs in headache treatment among American Headache Society members, 75.3% (122 practitioners) of the respondents used TPIs as part of their headache management (Table 1). The most common headache diagnoses in which TPI were performed were chronic tension-type headache (CTTH) (81.5%) and chronic migraine (CM) (67.7%)." 

Therefore TPI can be considered medically necessary for this patient and TPI charges (20553 x 5) should be approved. The health plan did not act reasonably with sound medical judgment in the denial of TPI. 

Nerve blocks were also performed. However, nerve blocks are not mentioned in the visit note, plan or the appeal letter; only TPI are mentioned. No information is provided to counter the insurer's decision to deny Nerve Block for Pain Management. Therefore, the nerve block procedures (64418 x5, 64400 x5, 64405 x5, 64450 x5) are not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient in the denial of the nerve block procedures. 

Based on the above, the medical necessity for Outpatient Procedure (20553 x5) is substantiated, but medical necessity for (64418 x5, 64400 x5, 64405 x5, 64450 x5) is not substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. 
The health plan's determination is upheld.

The patient is a man with hypertension (HTN), hyperlipidemia, type 2 diabetes mellitus and non-obstructive coronary artery disease (CAD) who had presented for a cardiology evaluation with exertional dyspnea with walking 15-20 minutes, and fatigue. A stress test done showed an anterior perfusion defect.
He was brought to the hospital and underwent cardiac catheterization via a radial approach. He was found to have a normal left main coronary, 70-80% proximal left anterior descending stenosis, 70% postal first diagonal, and mild circumflex and right coronary disease. Percutaneous transluminal coronary angioplasty (PTCA) and stenting was performed to the proximal left anterior descending (LAD) and PTCA to the first LAD diagonal. He was admitted overnight for observation and was discharged the next day.
At issue is the medical necessity of the inpatient stay.

It is recommended that the health plan's determination of medical necessity be upheld, in whole.

No, inpatient stay is not medically necessary for this patient. He was electively admitted for evaluation of exertional dyspnea and an abnormal stress test. He underwent cardiac catheterization and percutaneous revascularization to the left anterior descending and diagonal. He was hemodynamically stable throughout the hospitalization, and the procedure was uncomplicated. 
Observation status would have been appropriate for this patient who was electively admitted for a cardiac catheterization and had an uncomplicated percutaneous revascularization procedure.
Percutaneous coronary intervention is generally an ambulatory or observation procedure. Inpatient admission may be needed in certain cases, such as: unstable angina or acute myocardial infarction, requirement for glycoprotein IIb-IIIa receptor inhibitors, intravascular procedural complications, extravascular procedural complications ( such as retroperitoneal hematoma, pericardial effusion or tamponade), need for coronary artery bypass, entry site complications, causing significant bleeding or distal ischemia requiring monitoring or surgical intervention, or post procedural CVA (cerebral vascular accident). None of these situations apply in this case. Observation status would have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibromyalgia
Treatment: Savella (milnacipran)
The insurer denied coverage for Savella (milnacipran) to treat fibromyalgia.
The denial is overturned. 

This is a female patient with a history of Crohn's disease, fibromyalgia, hypertension, seizures, and anxiety. The patient was seen by her rheumatologist for her fibromyalgia. The patient reported having body aches all day. The patient reported that physical therapy only resulted in a slight improvement of back pain. The patient appeared to be sleepy with a lack of eye contact. The patient has attention deficit hyperactivity disorder (ADHD) and Adderall was recently stopped, and she was having trouble focusing. The physician assistant recommended continuing with gabapentin, trying to get Savella approved, continuing with pain management, continuing with neurology recommendations, and following up with the rheumatologist within 8 weeks. The patient has failed Cymbalta in the past.  At a recent office visit, the patient's current medications included cyclobenzaprine, gabapentin, Trileptal and Zoloft. 

At issue is the medical necessity of the denial of coverage for Savella (milnacipran) to treat this patient's fibromyalgia. The alternatives offered by the insurer are used in fibromyalgia, so they are appropriate considerations. However, there are specific circumstances for this case that affect their utility.

The medication list at the recent office visit lists, among others, cyclobenzaprine, gabapentin, and Zoloft. The only one mentioned in notes is the gabapentin, and this review will be done assuming gabapentin is the only one currently being taken. Savella would not be mixed with Zoloft or nortriptyline with cyclobenzaprine. 

Savella is a serotonin and norepinephrine reuptake inhibitor, and this medication has Food and Drug Administration (FDA)-approval for the treatment of fibromyalgia. As for the insurer's recommended/preferred medications, the use of tricyclic antidepressants (TCAs) such as nortriptyline and amitriptyline for pain management, while not FDA-approved, has been a longstanding well-studied use of these medications.  As per review of the literature, a tendency for serotonin and norepinephrine reuptake inhibitors to work better than TCAs is noted. Their use is discussed in UpToDate articles on "Pharmacologic management of chronic non-cancer pain in adults" and "Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects."

While Savella and the insurer's choices all share possible sedation/mentation and mood changes as side-effects, the risk is less with the serotonin and norepinephrine reuptake inhibitors, i.e., Savella when compared to TCAs. Thus, in this case, Savella would be a better choice for this patient. Savella is considered medically necessary for this patient.

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

The carrier's denial of coverage for Savella (milnacipran) to treat fibromyalgia should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth.
Treatment: Mandibular Partial Denture - Resin Base to Lower Arch (D5212).
The insurer denied the Mandibular Partial Denture - Resin Base to Lower Arch (D5212).
The denial is overturned. 

The patient is requesting dental benefits for lower resin base partial denture.

Yes, the proposed treatment with mandibular partial denture - resin base to lower arch (D5212) is medically necessary. 

The patient is missing six lower teeth. The remaining lower teeth reflect as in health and should be able to support a lower partial denture. The patient states he cannot chew properly with his missing teeth. Chewing properly is a health issue. The lower partial will give the patient a full compliment of teeth on the bottom to chew with and this will be better for his digestion. The lower denture is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hiatal hernia, Gastroesophageal Reflux Disease.
Treatment: The Linx procedure.

The insurer denied coverage for the Linx procedure. The denial is overturned.

This is a female patient with a history of anxiety, hiatal hernia, irregular heartbeat and Gastroesophageal Reflux Disease (GERD). She had an upper endoscopy and was found to have a 2 centimeter hiatal hernia with Grade B esophagitis. She now presented with heartburn and regurgitation and the tertiary symptom of throat clearing. The patient has had this condition for 3-5 years and her quality of life has been negatively affected. The patient has been taking acid suppression in the form of proton pump inhibitor (PPI) for 1.5 years. She denies that these symptoms are PPI responsive. The symptoms are primarily aggravated by post prandial. The plan was esophagogastroduodenoscopy (EGD) with Bravo and biopsy, manometry, and esophagram. The patient had a follow up telephone visit where the results were reviewed. It was noted that high resolution was abnormal; 48 hour pH [potential of hydrogen] testing was abnormal with DeMeester score of 32.2 on day 1 and 5.4 on day 2; 24 hour impedance pH testing was not performed; EGD was abnormal with no evidence of Barrett's esophagus with Los Angeles (LA) Grade B reflux esophagitis. Discussion ensued with the patient for therapeutic options for control of GERD. The plan was laparoscopic hiatal hernia repair with Linx placement.

High resolution esophageal motility study was performed and the impression was findings suggestive of ineffective distal esophageal motility as the cause of the patient's incomplete bolus clearance. There was no hiatal hernia present and no evidence of gastroesophageal junction (GEJ) outflow obstruction. Ambulatory pH monitoring was performed with the results of reflux monitoring summary Symptom association probability of 100% for heartburn correlating with acid exposure, and with a DeMeester total score of 19.8 and day 1 DeMeester score of 32.2. Esophagram was performed on and did not reveal a hiatal hernia or gastroesophageal reflux. Upper gastrointestinal (GI) endoscopy was done and did not reveal Barrett's esophagus with LA grade B esophagitis. Biopsy did not reveal intestinal metaplasia, dysplasia or neoplasia at the GEJ.

There is scientific evidence in peer reviewed literature to support and substantiate its improvement in health outcomes as well as its safety and effectiveness. The Linx procedure can improve health outcomes. As noted by Schwaitzberg in Up-to-date, eligible patients must demonstrate typical GERD symptoms, an abnormal pH study, partial response to daily PPI therapy, and absence of a large hiatal hernia (greater than 3 centimeters) or severe esophagitis. Based upon the records the insurer is incorrect in denying Linx as the procedure is indicated in this patient with a Grade B esophagitis with an abnormal DeMeester score. 

The plan did not act reasonably and with sound medical judgment in this case and in the best interest of the patient. 

The medical necessity for the Linx procedure is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vocal fold paralysis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient was diagnosed with a malignant thyroid neoplasm and underwent a thyroidectomy. This resulted in paralysis of the right recurrent laryngeal nerve. Her symptoms include dysphonia and dysphagia. Her exam revealed a right true vocal fold paralysis. She underwent a flexible laryngoscopy with a right implantation thyroplasty and a right pharyngoplasty. She was not intubated for this procedure. She did well postoperatively and was admitted overnight for airway monitoring and having had no sequalae, was discharged. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of an inpatient stay is not medically necessary for this patient based upon the clinical information provided and the peer reviewed medical literature.
Clinically, the patient was admitted for airway monitoring after medialization thyroplasty. Postoperatively, she remained afebrile. Her oxygen saturations ranged from 96 to 100% on room air and it is documented that she was breathing comfortably. Her voice was improved. She was able to tolerate the mechanically soft diet ordered; she experienced no postoperative bleeding. Although it is noted that the patient had hypotension postoperatively, this did not persist and she was not seen in consultation for persistent hypotension.  Therefore care could have been provided at a lower level than inpatient.
According to Ekbom et al (2019), same day discharge has become more common in medialization thyroplasty over the preceding 10 years and in a series by Attalah et al(2019), the authors concluded that the procedure was safe and effective with no postoperative complications noted. In a study by Chau in 103 patients, the adverse effects during and immediately following unilateral medialization laryngoplasty is very low and that patients can be discharged on the day of surgery without any geographic restrictions, such as staying near the facility in which the the procedure was performed.
Based upon the clinical information and the peer reviewed medical literature, admission postoperatively was not medically necessary.