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

Diagnosis: COVID Pneumonia (PNA). 
Treatment: Inpatient Hospital. 

The insurer denied the requested inpatient rehabilitation stay. 
The insurer's determination is upheld. 


The patient is a female admitted to the hospital secondary to complications from a COVID-19 infection, including COVID PNA and respiratory failure requiring intubation. This was a prolonged hospital course with a successful intubation. She was transferred out of the Intensive Care Unit (ICU). At question, did the health plan, in its determination of medical necessity, act reasonably, with sound medical judgment and in the best interest of the patient? 

This reviewer upholds, in whole, the health plan's determination of medical necessity. 

No, the requested health service of inpatient rehabilitation is not medically necessary for this patient. The patient is a female with a prolonged hospital course related to COVID-19 infection requiring intubation. While documentation did note multiple complications including, but not limited to, pneumonia and a urinary tract infection (UTI), her most recent documentation shows that she is doing well. For example, physical therapy noted that she was completing bed to chair transfers with supervision. Additionally, she was ambulating 80' with a rolling walker stand by assist (SBA) and 10' without a device contact guard assist (CGA). Endurance appears to be the main limiting factor which is understandable given her prolonged and complicated hospital course but that alone does not support acute inpatient rehabilitation. Additionally, with the impaired endurance this reviewer does not have confidence that the patient will be able to successfully participate in 15 hours of therapy per week. Documentation also did not support acute rehabilitation nursing, nor did it support the need for frequent physician visits. For example, the physician did not make any medication changes, the patient was not on any antibiotics and vitals were stable. The patient would benefit from therapy but in a lower level of care - such as a skilled nursing facility.
Appeal type: Medical necessity
Decision: Upheld

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

The patient has a past medical history (PMH) of hyperlipidemia (HLPD) and was admitted with complaints of (c/o) constant, substernal chest pain that was crushing in nature and associated with diaphoresis. By the time of the initial evaluation, the pain had subsided. Vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for negative troponin. A chest x-ray (CXR) showed no acute pathology, A transthoracic echocardiogram (TTE) showed no gross abnormalities and normal ejection fraction (EF). An electrocardiogram (EKG) showed no ischemic changes. The patient was diagnosed with atypical chest pain and treated with acute coronary syndrome (ACS) rule out (r/o) with serial troponins, clinical monitoring, and cardiology consultation. The patient's HEART [history, EKG, age, risk factors, and troponin] score was 4 and cardiology recommended the addition of acetylsalicylic acid (ASA) and an outpatient stress test. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the ED with c/o constant, substernal chest pain that was crushing in nature and associated with diaphoresis. An electrocardiogram (EKG) did not demonstrate any acute ischemic changes and he was evaluated by cardiology, who did not recommend any acute interventions. For the chest pain, the patient's HEART score was 4, indicating that the patient had a moderate score, not a high score. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and negative cardiac biomarkers, no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Headaches.
Treatment: Nerve Block Injection(s) Anesthetic Agent(s) and /or Steroid; Trigeminal Nerve (opthalmic maxillary mandibular).
The insurer denied the Nerve Block Injection(s) Anesthetic Agent(s) and /or Steroid; Trigeminal Nerve (opthalmic maxillary mandibular). 
The denial is upheld.

The patient is a woman with chronic migraines, which she has had for over 10 years followed by worsening of it. Late last year, she developed a lengthy episode of migraines that were refractory to acute migraine treatments, including sumatriptan, Toradol or medrol pack. Her provider did an urgent trigeminal and occipital nerve block with significant relief of her headaches after this procedure. The request for coverage for trigeminal nerve block was denied, because the procedure was considered Experimental/Investigative and therefore not covered.

No, the health plan should not cover the trigeminal nerve block.
There is a lack of research and evidence regarding trigeminal nerve block for treating acute migraines. A Pubmed search for supraorbital nerve block did not produce any high-quality evidence that it is beneficial and safe for an acute migraine attack. There is high-quality clinical evidence that it may be helpful for preventing migraines rather than aborting a migraine.

No, it is not evident that the trigeminal nerve block is more beneficial.
There is no high-quality evidence that nerve blocks are superior to the standard of care. Standard-of-care in status migrainosus includes intravenous fluids, corticosteroids, magnesium sulfate, anticonvulsive drugs, nonsteroidal anti-inflammatory drugs, antiemetics, and serotonergic agents.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Headaches.
Treatment: Nerve Block Injection(s) Anesthetic Agent(s) and /or Steroid; Trigeminal Nerve (opthalmic maxillary mandibular).
The insurer denied the Nerve Block Injection(s) Anesthetic Agent(s) and /or Steroid; Trigeminal Nerve (opthalmic maxillary mandibular) .
The denial is upheld.

The member is a female with chronic migraine headache disorder and post-traumatic headaches. The provider has requested trigeminal nerve injections.

No, the health plan should not cover the trigeminal nerve block.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
There are no high-quality clinical trials demonstrating that trigeminal nerve injections, or any peripheral nerve injection, improves outcomes for persons with migraine or post-traumatic headaches. The manuscript provided by the provider is not a randomized trial and does not reference any high-quality clinical trials to support the efficacy of this intervention. Standard-of-care guidelines do not support the use of peripheral nerve blocks, including trigeminal nerve blocks, for migraine abortion or prevention (Tepper, Tepper,, Burch).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Headaches.
Treatment: Nerve Block Injection(s) Anesthetic Agent(s) and /or Steroid; Trigeminal Nerve (opthalmic maxillary mandibular).
The insurer denied the Nerve Block Injection(s) Anesthetic Agent(s) and /or Steroid; Trigeminal Nerve (opthalmic maxillary mandibular).
The denial is upheld.

The patient is a female. There is a note indicating a request for trigeminal nerve block for treatment of headache.

Note indicates a procedure, block of trigeminal nerve, any division or branch, and indicates the procedure was performed on trigeminal nerve, greater occipital, lesser occipital nerve, auriculotemporal nerve blocks, supraorbital supratrochlear nerve block, and given Toradol 30 mg (milligrams) IM (intramuscular) for acute headache per the provider.

Per the note, the patient presented for nerve block, intractable headache.  Her pain was 8/10.

No, the health plan should not cover the trigeminal nerve block.
The use of multiple peripheral nerve blocks involving the head and face has not been demonstrated in peer-reviewed controlled trial publications to be beneficial for the treatment of headache.  The treatment is not recommended for treatment of migraine type headaches.

Position statements of American Headache Society and AAN (American Academy of Neurology) do not support the use of multiple head and neck peripheral nerve blocks for treatment of headache.

No, the trigeminal nerve block is not more beneficial.
There are multiple standard treatments for chronic and acute headache that are supported based on published research and FDA (United States Food and Drug Administration) indication, as well as non pharmacologic treatments that are supported by studies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Hypertension (CHTN)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a female with history of Grave's disease and chronic hypertension (CHTN) status post primary cesarean section. The patient presented to the Emergency Department (ED) with elevated blood pressure to 160s/100s at home with headache and blurry vision. The pregnancy was complicated by CHTN. She was admitted to the antepartum unit for post-partum preeclampsia. She was treated with 12 hours of magnesium sulfate for seizure precautions and labetalol 200mg (milligrams) three times per day. The patient was discharged home. Urinary protein was negative. Laboratory evaluation was normal.

This patient presented few days after delivery with elevated blood pressure. 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:

Systolic blood pressure greater than or equal to  (>=) 140 mmHg (millimeters of mercury) or diastolic blood pressure (>=) 90 mmHg, and 

1) Proteinuria ( >=) 0.3 grams in a 24-hour urine specimen or protein: creatinine ratio (>=) 0.3, or  

2) Signs of end-organ dysfunction (platelet count less than (<) 100,000/microliter, serum creatinine greater than (>) 1/1 mg/dL (milligrams per deciliter) or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, no protein in the urine was documented and no elevated liver function tests (LFTs) and no end organ dysfunction.  This patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure.

Ideally, this patient would have been observed in the ED. Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

The health care plan acted reasonably and 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: Medical necessity
Decision: Overturned

Diagnosis: Tooth fracture.
Treatment: Crown - Porcelain Fused to High Noble Metal (Tooth 6).
The insurer denied Crown - Porcelain Fused to High Noble Metal (Tooth 6). 
The health plan's determination is overturned.

The patient is a male who presents for evaluation and treatment of tooth # (number) 6. Provided for review are previous letters of appeal and denial, multiple radiographic images, two pages of American Dental Association (ADA) claim forms, a narrative from the provider, and a narrative from the patient.
In question is the medical necessity of the planned treatment of crown porcelain fused to high noble metal (D2750) for tooth #6.

The Crown - Porcelain Fused to High Noble Metal (Tooth 6) is medically necessary for this patient.
As the tooth has a documented fracture and as the tooth has received a root canal, the current plan of full coverage crown is the only treatment that can prevent the propagation of the fracture further. Hence the treatment of crown porcelain fused to high noble metal (D2750) for tooth #6 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest

Treatment: Inpatient hospitalization

The insurer denied coverage for inpatient hospitalization.

The denial is upheld.

The patient presented to the hospital complaining of chest pain. Past medical history was significant for gastritis.  The pain began on the morning of presentation and occurred at rest while eating breakfast. Upon arrival to the hospital, vital signs were stable (blood pressure [BP] 120/78, pulse 79 beats per minute). Relevant findings reported on physical examination included reproducible chest pain with palpation.  Twelve-lead electrocardiogram (ECG) revealed normal sinus rhythm with T (interval on ECG) wave inversions in the inferior leads and poor R (interval on ECG) wave progression in the precordial leads.  Serum blood testing revealed no elevation in troponin (<0.01 x2). The patient was admitted for observation overnight and sent for computed tomography angiogram (CTA) to assess for coronary artery disease the following day. She ultimately eloped from the hospital.

The health plan acted reasonably, with sound medical judgment and in the best 
interest of the patient.  This patient presented with atypical chest pain that was reproducible on physical examination and a past medical history of gastritis. Her pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART [history, ECG, age, risk factors, troponins] score she was considered low risk (Reference 2).  Utilizing the TIMI [thrombolysis in myocardial infarction] risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

Based on the above, the medical necessity for the inpatient hospitalization is not substantiated. The insurer's denial is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Mental Health/Attention Deficit Hyperactivity Disorder/ADHD.
Treatment: Pharmacy/Prescription Drugs (Adderall).
The health plan denied the requested medication as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with attention deficit hyperactivity disorder. Adderall 10 mg twice daily was 
prescribed for continued use. The provider stated that the patient had side effects with the generic formulation of the medication. The patient stated that the generic formulation of the medication causes headaches and difficulty sleeping and is less efficacious than the brand drug.
At issue is whether the requested medication would be as effective as other specific medications.

The health plan's determination is upheld, in whole.

No. The patient had a suboptimal response to and had side effects with amphetamine-dextroamphetamine. However, the patient has not failed or been intolerant to and has no contraindication to dexmethylphenidate, dextroamphetamine, and methylphenidate. In summary, dexmethylphenidate, dextroamphetamine, and methylphenidate have not been ineffective, would be as effective as Adderall, and would not be expected to have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty Ambulating/Wheelchair bound .
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 4 Days per Week, 12 Hours per Day [Sunday to Wednesday] - and - Personal Care Worker (PCW) Services: 3 Days per Week, 12 Hours per Day [Thursday to Saturday] - Total of 84 Hours per Week. 
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 4 Days per Week, 12 Hours per Day [Sunday to Wednesday] - and - Personal Care Worker (PCW) Services: 3 Days per Week, 12 Hours per Day [Thursday to Saturday] - Total of 84 Hours per Week. 
The health plan's determination is overturned.

The patient is a male with past medical history of benign prostatic hyperplasia (BPH), hypertension, chronic kidney disease, lymphedema, osteomyelitis of the spine, chronic pain, obesity, diabetes mellitus type 2, urinary incontinence, stool incontinence, and wheelchair dependence who had been assigned Consumer Directed Personal Assistance Services (CDPAS) based on assessment tool performed one year ago. assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of managing medication, stairs, transportation, bathing, and dressing lower body while limited assistance with tasks of managing finances, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating. The patient was assessed as independent with task of bed mobility.

Consumer Directed Personal Assistance Services (CDPAS): 4 Days per Week, 12 Hours per Day [Sunday to Wednesday] - and - Personal Care Worker (PCW) Services: 3 Days per Week, 12 Hours per Day [Thursday to Saturday] - Total of 84 Hours per Week medically necessary for this patient. 
There is documentation from the patient's primary care physician, physical therapy and rehabilitation notes that the patient has had a decline in functional capacity relating to osteomyelitis of the spine. The patient requires assistance with all ADLs(Activities of Daily Living). The patient has documented urine and stool incontinence with a wound on his back. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The insurer assumed the patient had informal care outside of the hours of current CDPAS services. Adaptive equipment and medical supplies alone will not meet the patient's care needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 hours/day, 4 days/week, and PCA services 12 hours/day, 3 days/week to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Low back pain and leg pain.
Treatment:  Back Surgery [CPT (Current Procedural Technology) 63042, 63044, 22849, 22630, 22852, 22842, 22612, 22614, 20930, 20936, 20939, 61783, 76000].

The insurer denied Back Surgery [CPT 63042, 63044, 22849, 22630, 22852, 22842, 22612, 22614, 20930, 20936, 20939, 61783, 76000].  The health plan's determination is upheld.

This is a female with a history of low back pain and leg pain and prior lumbar fusions at L (lumbar) 3-4 and L5-S (sacral).  She had a revision of her L3-4 fusion before due to a dislodged cage. There is no documentation of recent conservative therapy. She is a former smoker. The neurologic exam shows no motor or sensory abnormalities. The lumbar magnetic resonance imaging (MRI) shows post-operative fusion at L3-4 and L4-5. There are no abnormalities at L4-5 described. A computed tomography (CT) lumbar shows mild spinal stenosis at L4-5 with incomplete fusion at L3-4 and post-operative changes at L5-S1. Flexion/extension x-rays showed no evidence of pseudoarthrosis or instability.

The provider has recommended and L4-5 interbody fusion and L3-S1 decompression and posterior fusion. This is the subject of this review.

Back Surgery [CPT 63042, 63044, 22849, 22630, 22852, 22842, 22612, 22614, 20930, 20936, 20939, 61783, 76000] is not medically necessary for this patient. The indications for the procedure are not clear. The provider describes severe spinal stenosis at L4-5, however, this is not described on the lumbar MRI or CT. There is no evidence of pseudoarthrosis at L5-S1 or L3-4, although the CT scan describes L3-4 to not have complete fusion. It should be noted that the patient has had 2 attempts at fusion previously at L3-4.

From the standpoint of adjacent level disease, pseudoarthrosis or instability, the procedure is not indicated. Additionally, there is no documentation of conservative therapy that has been done.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Prograf. 
The denial is overturned. 

The patient is a female with a history of a simultaneous pancreas and kidney transplant. She presented for follow up. Her transplant course has been complicated by emesis requiring multiple admission within the first month after transplantation. She has not had any episodes of rejection and reports good graft function. She is currently on Myfortic, Prograf and prednisone for immunosuppression. Her health care plan has denied a formulary exception request for her Prograf stating that there are alternative medications available which are equally efficacious, and that the member has not demonstrated that she has tried and failed these alternative options. The prescribing physician notes that the patient was on generic tacrolimus but did not tolerate it due to chronic nausea. The patient therefore needs Prograf as part of her maintenance immunosuppression regimen. 

The health plan's determination is overturned. 

The patient has a history of a simultaneous kidney and pancreas transplant and requires long term immunosuppression with Myfortic, prednisone and the calcineurin inhibitor tacrolimus. The patient is unable to tolerated generic tacrolimus due to documented nausea and emesis. She can however tolerate the Prograf formulation. A cyclosporine-based regimen is not an equivalent option. Tacrolimus is superior to cyclosporine in improving graft survival and preventing acute rejection after kidney transplantation. Tacrolimus treatment is also associated with a significantly better cardiovascular risk profile and superior renal function compared with cyclosporine microemulsion treatment, which appears to translate into improved long-term graft survival. A cyclosporine-based regimen would only be an option if the patient could not tolerate any of the tacrolimus formulations. The patient should remain on a tacrolimus-based regimen to ensure a lower risk of acute rejection and improve changes on long-term survival. Since she is unable to tolerate the generic formulation, Prograf will be more effective and is the appropriate alternative for this patient.