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

Diagnosis: Chronic gastroesophageal reflux disease (GERD) 
Treatment: Esophagogastroduodenoscopy (EGD) 
The insurer denied: Esophagogastroduodenoscopy
The denial is upheld

The patient is an adult female with chronic gastroesophageal reflux disease (GERD) despite Prilosec 20 milligrams (mg) daily. There is no weight loss, vomiting, dysphagia, anemia or gastrointestinal (GI) bleeding. The attending physician (AP) has requested esophagogastroduodenoscopy (EGD).

No, the proposed esophagogastroduodenoscopy (EGD) was not medically necessary. 
Esophagogastroduodenoscopy (EGD) is medically necessary in the evaluation of gastroesophageal reflux disease (GERD), when patients' symptoms are refractory to more than two months of high dose proton pump inhibitors, or are associated with alarm symptoms of weight loss, vomiting, dysphagia, anemia or gastrointestinal (GI) bleeding. 

This patient has been taking Prilosec 20 milligrams (mg) daily, but there is no evidence of the patient taking more than two months of high dose proton pump inhibitors. There is also no evidence of gastroesophageal reflux disease (GERD) being associated with alarm symptoms of weight loss, vomiting, dysphagia, anemia or gastrointestinal (GI) bleeding.

Therefore, the requested esophagogastroduodenoscopy (EGD) was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion with moderate upper and lower arch crowding.
Treatment: D8080 Braces
The insurer denied D8080 Braces
The denial is overturned

The patient is a young male. The request is for orthodontic benefits. He has a Class I malocclusion with moderate upper and lower arch crowding.

Coverage for the braces was denied by the health plan due to a Salzmann score of 23. The denial is being appealed.

Yes, the requested braces are medically necessary.
The patient has a deep, impinging overbite where the lower incisors are causing damage to the upper palatal gum tissues. This is an "automatic qualifier." Therefore, the requested braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Epidural steroid injection (62323).
The insurer denied coverage for epidural steroid injection (62323). 
The denial is upheld.

This is a patient with chronic back pain and underlying spinal stenosis. She underwent a lumbar epidural steroid injection. Under review is the medical necessity of another epidural steroid injection (62323).

The clinical records do not support the medical necessity of another epidural steroid injection (62323). Contrary to the doctor's note, she does not document any pain or functional improvement in her office visit note. The patient was seen by her doctor for follow-up of back pain. She noted the patient "did have a series of 3
LESIs (Lumbar Epidural Steroidal Injections)." However, no significant improvement was reported or documented. In her external appeal, the patient also does not report any improvement from the first epidural steroid injection, noting with previous injections; "it was not until the 2nd round that improved by back pain." This physician agrees with the insurer that the lack of documented improvement does not support the medical necessity of repeating the requested lumbar epidural steroid procedure.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. (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/pain management perspective, as well as within a reasonable degree of medical certainty, the requested epidural steroid injection (62623) is not medically necessary.

The insurer's denial of coverage for epidural steroid injection, 62323 is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins and pelvic congestion. 
Treatment: Vascular embolization. 
The insurer denied coverage for vascular embolization. 
The denial is overturned. 

The patient has a history of severe vulvar varicose veins and pelvic pain. The patient underwent ovarian vein and doppler, which demonstrated dilated ovarian veins with reflux. Her right ovarian vein was found to be 3.4 millimeters (mm) to 2.2 seconds of reflux and the left ovarian vein measured 4.4 mm with over 6 seconds of reflux. The patient underwent further evaluation with magnetic resonance (MR) venogram, which demonstrated enlarged ovarian veins with bilateral reflux with pelvic varices compatible with Pelvic Congestion Syndrome. Her diagnostic pelvic venogram showed 80% stenosis of common iliac vein origin due to crossing iliac artery. 

The insurer has denied coverage for vascular embolization. In their Final Adverse Determination letter, they write that based on the criteria and lack of peer-reviewed literature, endovascular occlusion of the ovarian and/or internal veins has not been medically proven to be effective and is considered investigational for the treatment of pelvic congestion syndrome. 

In an appeal letter, the provider writes that the patient has presented symptoms consistent with Pelvic Congestion Syndrome (PCS). MR venogram of the pelvis showed enlarged ovarian and pelvic varicosities. Ovarian vein embolization (OVE) treatment has been found to be an effective procedure with good clinical outcomes for patients suffering from PCS symptoms. Symptomatic improvement was seen in over 80% of patients undergoing OVE. 

This patient has both vulvovaginal varicosities and pelvic pain. While medical treatment for pelvic congestion syndrome (PCS) with gonadotropin-releasing hormone agonists or synthetic progestins is recommended and effectively decrease pain associated with pelvic congestion it will not help with vulvovaginal varicosities. 

If vulvar varices are present, evidence from case reports and small series shows that treatment of ovarian vein reflux leads to reduction in the size of vulvar varicosities and improve pain. Embolization is preferred to vein ligation because it is safe, well-tolerated, and allows for a minimally invasive approach. 

While there are no randomized controlled trials with ovarian vein embolization for patients with PCS and vulvovaginal varicosities, as those will be very difficult to conduct, there are not any other option for treatment that is available. 

Based on this patient's history, physical and radiological findings and due to the fact that she has undergone multiple venous closure procedures of the left leg with recurrence, the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of vascular embolization should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins and pelvic congestion. 
Treatment: Vascular embolization. 
The insurer denied coverage for vascular embolization. 
The denial is overturned. 

The patient has the medical diagnosis of severe varicose veins and pelvic congestion. The patient has been seen and treated with severe varicose veins and pelvic congestion. The patient complains of painful leg varicosities and pelvic cramping with heaviness. The patient's workup has included pelvic ultrasound, MRV [magnetic resonance venogram], and pelvic venography: all of which show dilated, refluxing ovarian veins with pelvic varicosities. The venogram show stenosis of the left common iliac vein as well. The treating provider wishes to perform pelvic vein embolization, which plan is denying as an experimental therapy. The treating provider is requesting plan approval for treatment with vascular embolization. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Although many plans do consider the procedure experimental, peer-reviewed literature does exist which supports an improvement in health outcome with pelvic vein embolization in certain patients such as this. 

Vascular embolization procedure is certified and supported by the Society of Interventional Radiology. The sclerosants and coils used in the procedure are Food and Drug Administration (FDA) approved. 

This patient is a good candidate for vascular embolization. All the diagnostic testing confirms large, refluxing ovarian veins, with pelvic varicosities. 

Given her clinical presentation and diagnostic testing results, pelvic vein embolization is the best treatment for her at this time.  The adverse risks are not increased over standard treatment and/or services. 

The pelvic vein procedure is both safe and well tolerated, with no significant reported adverse events. 

The patient complains of painful leg varicosities and pelvic cramping with heaviness despite conservative treatments. The treating provider is requesting plan approval for treatment with vascular embolization. The challenge with these patients is no standard procedures exist other than compression hose and bed rest, which are not satisfactory for a woman of this age to do long term. Significant literature exists supporting the benefit of treating this type of patient with the diagnosis of pelvic vein congestion proven by 3 diagnostic imaging studies. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of vascular embolization should be overturned.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Anemia
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is modified.

This patient presented to the emergency department (ED) with complaints of bilateral flank pain and bilateral lower extremity edema and was admitted with symptomatic anemia. Upon examination she had leg swelling with no deep vein thrombosis (DVT) on imaging. Lab values showed a Hemoglobin (Hgb) of 4.4 and a Hematocrit (hct) of 15.5. The patient was admitted and was given two units of packed red blood cells while in the ED. She was also administered Protonix and Tylenol. Imaging revealed a subchondral cyst like lucency of the left acetabular roof. The patient's vital signs were stable and her Hgb level showed improvement following treatment.

"Routine endoscopy in children and adults is usually performed in an outpatient setting using parenteral or general anesthesia." (Ahlawat R, Hoilat GJ, Ross AB, 2022)

"Anemia is a reduction in hemoglobin (Hb) or hematocrit (HCT) or RBC (red blood cell) count. It is a presentation of an underlying condition and can be subdivided into macrocytic, microcytic, or normocytic. Patients with anemia typically present with vague symptoms such as lethargy, weakness, and tiredness. Severe anemia may present with syncope, shortness of breath, and reduced exercise tolerance." (Turner J, Parsi M, Badireddy M, 2022)      

The patient presented with symptomatic anemia and was transfused with two units of RBC's in the emergency room (ER) for a low Hgb of 4.4. Once that was completed there was no longer any reason to keep her in the hospital. The medical records indicate the patient received another unit of RBC. The lytic acetabular lesion did not require a continued stay and could have been worked up as an outpatient. A deep vein thrombosis (DVT) was ruled out while in the ED. The patient underwent an endoscopy and colonoscopy in the hospital, which are outpatient procedures. The reviewer of systems (ROS) and physical examination (PE) were non-contributory. The patient could have been discharged to complete the work up as an outpatient.

The insurer's denial of coverage for the inpatient hospital admission is modified. Allow the admission from day 1 to day 2 but uphold denial of day 3 to day 4.  Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Sacroiliitis
Treatment: Pain Management; pain injection (27096 x 2)
The insurer denied coverage for Pain Management; pain injection (27096 x 2)
The denial is overturned.

This woman has chronic low back pain. She has tried physical therapy and a home exercise program. She has had medication trials of gabapentin and tramadol.  Physical examination suggests the diagnosis of bilateral sacroiliitis. The request is for bilateral SI (sacroiliitis) joint injection. 

The health plan cites a guideline that suggests if there is more than one probable pain generator then an SI joint injection should not be performed. That is not an evidence-based conclusion. Many patients have multiple pain generators and requiring the "cure" of one before proceeding to address the others is not evidence based. In this patient, the physical exam supports the diagnosis of sacroiliitis. It is medically reasonable and necessary to perform a diagnostic SI joint injection to confirm the diagnosis. 

Zheng et al (1) conducted an evidence-based review and concluded:
"Injections into the SIJ (sacroiliac joint) may offer both diagnostic and therapeutic value. In a proportion of patients, they are generally effective for the short-term control of SIJ-mediated pain with minimal associated risk. Palpation-guided injections have poor accuracy and as such, image guidance is needed for accuracy. Fluoroscopic guidance is preferred, which allows for both confirmation of intra-articular needle placement and rule out of intravascular needle tip position by observation of contrast injection prior to injectate delivery."

MacVicar (2) published Appropriate Use Criteria from a multi-specialty group, and they concluded:

"These Appropriate Use Criteria (AUC) state that ideal candidates for SIJ injections should report pain that has been present for more than 1 month with an intensity of greater than 4/10. Conservative therapy such us over-the-counter medications and physical therapy should be trialed prior to injection. Injections may still be appropriate for pain of lesser intensity and duration if the pain causes functional limitation despite trial of conservative management. Per the AUC, repeat injection with steroid may be appropriate if there is 75% (percent) or more relief from a diagnostic, local anesthetic SIJ injection, or if there was at least 50% relief for at least 2 months after the first injection to suggest that the patient benefited from steroid effect."

The patient meets these criteria, and the requested injection is medically reasonable and necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the insurer's denial is overturned. The medical necessity for Pain Management; pain injection (27096 x 2) services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ischemic heart disease
Treatment is Eliquis (apixaban)
The insurer denied coverage for Eliquis (apixaban).
The denial is upheld.

This is the case of a male with a history of ischemic heart disease, preserved left ventricular ejection fraction (LVEF), palpitations, and pulmonary embolism. He is currently treated with Eliquis therapy.  

The formulary drug, rivaroxaban/Xarelto is not likely to cause the patient an adverse reaction. The formulary drug has not been ineffective, and no documentation is provided to support that the patient has ever been treated with rivaroxaban. Both Eliquis and Xarelto therapies have been found to be non-inferior to warfarin. The 2019 American Heart Association (AHA), American College of Cardiology (ACC) and Heart Rhythm Society (HRS) Guidelines provide a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin. This recommendation was based on several randomized clinical trials that enrolled thousands of patients. The direct thrombin inhibitor medications and the Factor Xa (xabans) inhibitor medications (including Xarelto/Rivaroxaban) were at least non inferior and in some cases superior to warfarin therapy. When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism. In a study of individuals with pulmonary embolism, Xarelto/rivaroxaban was safe and efficacious in treating pulmonary embolism. 

In conclusion, the patient may be treated with Xarelto. There is no evidence provided to demonstrate intolerance to the formulary medications. The requested drug would not be more effective than the formulary drug.

The formulary drugs are not expected to cause adverse effects. The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication. The formulary drug is not expected to be ineffective. The requested drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Eliquis (apixaban) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This patient presented to the Emergency Department (ED) with complaint of severe right flank pain x 5 days, fever with temperature max 103 Fahrenheit, dysuria, urinary frequency. In the ED she was found with temperature 101.2 Fahrenheit, heart rate 145, and hypotensive. Exam revealed right lower quadrant (RLQ) abdominal tenderness, right costovertebral angle tenderness (CVAT), dry mucous membranes. Labs: white blood cell (WBC) count 15,900, lactate = 2.6, urinalysis - moderate leukocytes, positive nitrites, positive red blood cells. In the ED, the patient was given intravenous (IV) fluids 2 liters, IV tramadol, IV Rocephin, admitted for treatment/management of acute pyelonephritis. She improved and was discharged to home. The insurer has denied coverage as not medically necessary. They noted the absence of unstable vitals, blood infection, or inability of kidneys to function and produce urine. The insurer felt that the patient's care could have been provided at the observation level of care. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guideline (MCG) Health (25th) Urinary Tract Infection (UTI) Rapid Review Guideline (RRG), patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, altered mental status, immunocompromised status, ureteral obstruction, pregnancy > 24 weeks gestation, persistence or worsening of clinical findings despite observation care (fever, pain, dehydration, vomiting).

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is a patient with a history of asthma and complaints of recurrent syncope. The patient reported passing out twice while having heated arguments and a third time while riding his bicycle. He noted rib pain after falling off of his bicycle. He came to the Emergency Department (ED) sometime after the events- unclear how long since the last episode of syncope. 

Upon arrival to the hospital vital signs were stable, Pulse 88 beats per minute, blood pressure 132/78. No orthostasis was noted. Physical examination was significant for a transverse scar across the abdomen and right rib tenderness. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm without any abnormalities. Serum blood testing revealed anemia with a hemoglobin of 11.2 and mean corpuscular volume (MCV) of 88.9, normal troponin (<3.5). Computed tomography (CT) scan of the head was unrevealing. The patient was admitted for observation and diagnostic testing. An echocardiogram was scheduled to assess for hypertrophic obstructive cardiomyopathy (HOCM). Apparently not done. The patient signed out against medical advice (AMA) prior to performance of any other diagnostic testing such as echocardiogram. 

This patient presented with multiple episodes of syncope that occurred while having an argument. The patient also reported that he lost consciousness while riding a bicycle. He had multiple episodes of syncope in a short period of time and presented to the hospital sometime after the last episode for evaluation and treatment. Upon arrival vital signs were stable and laboratory blood testing revealed anemia. He did require an echocardiogram in view of his syncope; however, this should have been completed the day after admission. He eventually signed out AMA before echocardiography or additional work up was performed. 

According to the European Society of Cardiology, patients presenting with syncope must be risk stratified for future morbidity and mortality in order to determine the need for hospital admission. (Reference 1) In a study of individuals presenting to the emergency room, patients that were high risk for cardiac events had a poor prognosis and required admission to the hospital for additional testing and treatment. (Reference 2) In this case, the patient was anemic, an unusual finding for a male of his age. This per se could be evaluated as an outpatient. As noted, the echocardiogram should have been performed earlier and thus with all other testing complete with no acute findings, the evaluation and need for acute inpatient admission could have been determined during a period of observation. 

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD
Treatment: Diagnostic Testing (other than radiology); (EGD) 
The health plan denied the requested procedure of an esophagogastroduodenoscopy as not medically necessary. 
The health plan's determination is upheld.

This is review for the medical necessity for an esophagogastroduodenoscopy (EGD) to evaluate gastroesophageal reflux disease (GERD) in a patient. This male had an EGD for the evaluation of GERD. The medical records provided do not indicate that he was on a proton pump inhibitor (PPI) or other acid suppressive medication prior to the EGD. The pre anesthesia records lists his only medications Aspirin and Cholestroloff.
At issue is whether the esophagogastroduodenoscopy was medically necessary.

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

No, the requested health service/treatment of EGD is not medically necessary for this patient. An EGD is not the first test in the management of GERD without an adequate trial of a PPI.
According to the current American College of Gastroenterology Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease, patients presenting with typical symptoms of heartburn and regurgitation should be given empiric medical therapy with a proton pump inhibitor. The diagnosis of gastroesophageal reflux disease is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy. Empiric proton pump inhibitor therapy (trial) is a reasonable approach to confirm gastroesophageal reflux disease when it is suspected in patients with typical symptoms. There is no indication that the patient has had an appropriate trial and failure of proton pump inhibitor therapy for 4-8 weeks to manage his symptoms. Therefore, an esophagogastroduodenoscopy for this patient would not be in accordance with generally accepted standards of medical practice or clinically appropriate, in terms of type, frequency, extent, site and duration for the patient's illness. The EGD in this patient was not medically necessary.