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

Diagnosis: Cervical spondylosis and radiculopathy
Treatment: Pain management (facet joint injections)
The insurer denied coverage for pain management (facet joint injections)  
The denial is overturned

This woman has a history of cervical spondylosis, radiculopathy, and persistent headaches. Prior treatment has included epidural injections and cervical facet joint injections. In the office visit note, the patient stated that the last facet joint injection caused worsened pain (this was apparently intra-articular). Treatment options were discussed, and the request was a medial branch block to left C (cervical) 3-C4 and left C4-C5.

While the intra-articular facet blocks did not provide significant pain relief, there is not a direct correlation with medial branch blocks. Disrupting the joint capsule can be very painful. National Medicare coverage criteria (1) require 2 sets of medial branch blocks prior to RFA (Radiofrequency ablation). Clinical practice guidelines (2) also support performing medial branch blocks prior to performing RFA.

Clinical practice guidelines (2) on "Cervical Spine (medial Branch blocks) state:
The level of evidence is level II (2) with moderate strength of recommendation.
Ten relevant diagnostic accuracy studies, 9 of the 10 studies with either controlled comparative local anesthetic blocks or placebo controls with concordant pain relief with a criterion standard of >= 80% were included.
The prevalence and false-positive rates ranged from 29% to 60% and of 27% to 63%, with high variability." There are no guidelines for intra-articular blocks prior to RFA. Diagnostic Medial branch blocks are medically reasonable and necessary for this patient.

The insurer's denial of coverage for pain management (facet joint injections) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Abdominal/Stomach Pain.
Treatment: Esophagogastroduodenoscopy.
The health plan denied the requested esophagogastroduodenoscopy. 
The health plan's determination is overturned.

The patient is a male. He had moderate epigastric pain (worse with food intake) and bloating for 2-3 months. Sleeve gastrectomy was planned. An esophagogastroduodenoscopy for the indication of dyspepsia showed a nodular gastroesophageal junction, mild patchy gastric erosions, four moderate-sized antral ulcers with nodular mucosa, and a normal duodenum; biopsies were positive for Helicobacter pylori. An esophagogastroduodenoscopy was repeated. 
At issue is the medical necessity for the requested health service/treatment of an esophagogastroduodenoscopy (EGD).

The health plan's determination is overturned, on whole.

Yes, an esophagogastroduodenoscopy is supported as medically necessary, based on the information provided. Bariatric surgery is planned, and the patient had epigastric pain and dyspepsia. Some types of surgery are not appropriate for patients with gastrointestinal pathology related to reflux. Medical literature states that "preoperative esophagogastroduodenoscopy is indicated before sleeve gastrectomy" due to the potential for findings such as Barrett's esophagus which require specific management [1]. Sleeve gastrectomy is associated with reflux and Barrett's esophagus, including a 15% to 17% incidence of de novo Barrett's esophagus without any correlation to symptoms [2]. A finding of Barrett's esophagus or reflux esophagitis could change management in this case, and the patient was found to have gastric ulcers. Large studies have supported pre-surgery endoscopy in patients with reflux disease [3,4]. Biopsies are indicated for finding pathologies such as esophagitis or gastritis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arterial disease.
Treatment: Ambulatory Surgery (Procedure to Fix Clogged Blood Vessels in Kidneys)  
The insurer denied Ambulatory Surgery (Procedure to Fix Clogged Blood Vessels in Kidneys) . 
The health plan's determination is upheld.

The patient is a man with an extensive history of arterial disease who underwent a scan with contrast which noted bilateral moderate stenosis of the renal arteries in addition to another arterial occlusive disease. In particular, it noted lower extremity occlusive disease in the right leg, which has previously undergone endovascular and bypass procedures.

Ambulatory Surgery (Procedure to Fix Clogged Blood Vessels in Kidneys) is not medically necessary for this patient.

American College of Cardiology (ACC) / American Heart Association (AHA) guidelines recommend revascularization in patients with hemodynamically significant renal artery stenosis and: recurrent congestive heart failure or sudden unexplained pulmonary edema; unstable angina; accelerated, resistant, or malignant hypertension and intolerance or resistance to medication. Interventional treatment of asymptomatic renal artery stenosis is clinically unproven. In this case, the patient does not have any of the above. Therefore, the requested treatment is not indicated at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal - Rheumatoid Arthritis (RA).   
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Orencia ClickJet. 
The denial is upheld.

The patient is a male with moderate to severe rheumatoid arthritis (RA). Another past medical history (PMH) includes obesity, myocardial infarction (MI), atrial fibrillation (AF), obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), hypertension (HTN), and prostate cancer (CA). Prior treatment includes by-mouth (PO) methotrexate (MTX), Enbrel, and Arava. The issue, in this case, is the medical necessity for subcutaneous (SQ) Orencia. He is currently on SQ Orencia (samples) with improvement. The plan preferred drugs are Humira, Enbrel, Kevzara, or Xeljanz.

The health plan's determination is upheld.

The requested treatment with Orencia ClickJect is not medically necessary for this patient. There is no medical reason the patient cannot try the plan preferred drugs,  including Humira or Kevzara, the patient does not have any contraindications to these drugs. These drugs are indicated for moderate to severe RA. Xeljanz would not be appropriate given the patient's history of MI and AF.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer.
Treatment: Lynparza.
The insurer denied Lynparza. 
The health plan's determination is upheld. 

This is a female with a history of stage IIA breast cancer. The patient is BRCA2 (breast cancer gene 2) positive and has received neoadjuvant paclitaxel. She is currently on anastrozole. Adjuvant olaparib (Lynparza) has been recommended and is under review.

Lynparza is not medically necessary.

Based on the results of the Tutt, et al trial as published in The New England Journal of Medicine (NEJM), the National Comprehensive Cancer Network (NCCN) recommends consideration of adjuvant Lynparza for patients with a germline BRCA 1/2 mutation and:
1) triple negative breast cancer meeting certain characteristics and
2) HR (hormone receptor) + (positive), HER2 (human epidermal growth factor receptor 2)- breast cancer patients with 1) > (greater than) 4 lymph nodes positive or 2) residual disease after preoperative therapy and a clinical stage, pathologic stage, estrogen receptor status, and tumor grade score >3.
Based on the included documentation, this patient does not meet any of these criteria other than having a germline BRCA2 mutation. There is a paucity data indicating that a patient in this clinical scenario would derive a benefit from olaparib and, therefore, its use in this setting is not recommended by the NCCN, the authors of UpToDate, nor by the peer-reviewed literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis.
Treatment: Dupixent Syringe 300 milligrams (mg).
The insurer denied coverage for Dupixent Syringe 300 mg.
The denial is overturned.

The patient is a female with severe atopic dermatitis who has failed therapy with mometasone, triamcinolone, tacrolimus, and betamethasone. Due to the severity of disease the patient now requires systemic therapy. The requested medication is Dupixent.  

Based on the submitted documentation, Dupixent is medically necessary for this patient. The patient has failed reasonable topical options for the treatment of her atopic dermatitis. Her disease is severe and requires systemic therapy. The use of a traditional oral immunosuppressive is not Food and Drug Administration (FDA) approved for atopic dermatitis and carries a significantly higher risk of complications and adverse side effects for a teen compared to FDA approved Dupixent. 

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 Dupixent Syringe 300 mg (milligrams) is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Knee osteoarthritis.
Treatment: Euflexxa 10mg/mL SYN.
The insurer denied the Euflexxa 10mg/mL SYN.
The denial is upheld.

The patent is a female with the diagnosis of right knee osteoarthritis and subjective complaints of right knee pain that has been increasing over the past few months.  The patient had Euflexxa injections in her knee about a year ago with relief of symptoms. Conservative treatment has included medications with minimal relief. There are no positive physical examination findings during the most recent office visit.  Right knee x-rays documented moderate osteoarthritic changes. 

The request is for Euflexxa, ten milligrams per milliliter (mg/mL) syringe. 

Adverse determination occurred as medical records did not document an evaluation of the knee with imaging results, tried and failed intraarticular steroid injections for at least three months, failed nonpharmacological treatment to include weight loss, physical therapy, bracing, trial of analgesics for at least three months, you will not be scheduled for a total knee replacement within six months of requested medication, and knee pain interferes with functional activities.

No, the requested Euflexxa injection for right knee osteoarthritis is not medically necessary.
While the patient has right knee osteoarthritis on imaging and subjective complaints of right knee pain, the only available office visit does not document previous trial of physical therapy or home exercise program. Further, there are no knee physical examination findings in the available medical records. 

The literature does support repeat injections of viscosupplementation. "In patients who previously improved with VS, retreatment can be considered as soon as pain recurs or increases again." (1) While there was documented benefit from the previous Euflexxa injection a year prior, there is no documentation of improvement in function and decrease in visual analog score (VAS).  With regards to the available medical records, the requested Euflexxa injection is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The provided medical records do not support the use of Euflexxa with regards to standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left heart catheterization
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This presented for elective left heart catheterization (LHC) for evaluation for transcatheter aortic valve replacement (TAVR). Her past medical history (PMH) is
pertinent for severe aortic valve stenosis. There was no significant associated coronary artery disease (CAD) and no procedural complications and she was discharged to home the same day.
This is an appeal of the denied claim the requested acute inpatient hospital stay was medically necessary for this patient.

No, the proposed treatment, inpatient hospital admission, was not medically necessary.

In this particular case, the patient underwent elective, successful and uncomplicated cardiac catheterization with coronary angiography on the same day. The information provided does not support the medical necessity for inpatient admission for this patient. This procedure is routinely performed in the ambulatory setting unless there is documentation of unstable medical conditions like hemodynamic instability, respiratory distress, pulmonary edema, acutely decompensated congestive heart failure (CHF), acute myocardial infarct (AMI), contrast nephropathy, life-threatening cardiac arrhythmia, procedural complications like serious vascular injury or stroke, or other medical instability or acute care needs that would require acute inpatient management.

The care this patient received is routinely provided safely and effectively at the ambulatory level of care under these circumstances. Therefore, based on the submitted information and the current, evidence-based published medical guidelines, the proposed treatment is not medically necessary.

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

Diagnosis: Substance abuse
Treatment: Substance Use-Inpatient Rehabilitation Treatment
The insurer denied Substance Use-Inpatient Rehabilitation Treatment. The health plan's determination is upheld.

The case involves a male who was referred from another facility after detoxification with admission to inpatient rehabilitation and substance use disorder treatment to address substance use disorder with alcohol and cocaine use. The patient had no history of blackouts or withdrawal seizures or delirium tremens. He had been using up to 4 pints of liquor daily with intermittent use of crack cocaine with a frequency of three times per month. He had multiple past treatments with residential and outpatient substance use treatment. His drug screen was positive for cocaine and his blood alcohol level was zero with no significant withdrawal symptoms. He reported craving and urges to use.

The proposed treatment could have been safely and effectively provided at a lower level of care in a less restrictive treatment setting. The clinical features and indicated treatment dimensions of this patient's alcohol and cocaine use disorders did not require or warrant the structure of an inpatient setting. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cocaine. Moreover, the patient had been evaluated and cleared with regard to safety concerns, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Excess Skin
Treatment:  Removal extra skin on the arms and chest/wound closure.

The insurer denied Removal extra skin on the arms and chest/wound closure.  The determination is upheld.

The patient lost weight following bariatric surgery and has had significant weight loss. She has excess upper arm, shoulder and chest skin that is causing irritation. She has treated the irritation with Balmex cream and Monistat without improvement. She is on immunosuppression due to multiple sclerosis. Her surgeon recommends bilateral brachioplasty and excision of chest rolls. At issue is the medical necessity of removal extra skin on the arms and chest/wound closure.

The requested procedures are not medically necessary. In this case, the primary goal is to improve appearance. The records do not provide physician office note documentation of ongoing health problems that have not responded to appropriate physician supervised medical management. The plastic surgery notes mention ongoing rashes, but primary care physician (or provider) (PCP) or dermatology notes documenting ongoing health problems are not provided to confirm that medical management supervised by a physician has been attempted and failed. Physician management of rashes is the safest initial approach to management of skin rashes. The records do not note any rare circumstances that mandate treatment with brachioplasties. According to a 2010 outcome analysis of brachioplasty surgery, "Patients report improvement in contour and self-esteem, and a high level of satisfaction with this procedure, despite the potential for an unfavorable scar." This study found improvements in self-esteem and contour but did not describe medical benefits from brachioplasty surgery. According to Sergesketter et al.: "Brachioplasty has become one of the fastest-growing aesthetic surgery procedures, paralleling rising rates of weight loss surgery nationally." Physician supervised treatment is the simplest, safest method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Shoulder Problem/Pain.
Treatment: Chiropractic Services.
The health plan denied the requested chiropractic service as not medically necessary. 
The health plan's determination is upheld.

The patient began chiropractic treatment for bilateral shoulder pain, Visual Analog Scale (VAS) 7/10, with initial examination findings of cervical subluxation, mildly reduced ranges of motion and positive shoulder depressor and compression. The treating diagnoses were cervical sprain/strain, subluxation and radiculopathy. Treatment included spinal manipulation and manual therapy, with home instruction to use ice, as needed.

At issue is the medical necessity for the requested chiropractic therapy.
The health plan's determination of medical necessity is upheld, in whole.

The chief complaint was bilateral shoulder pain, not spinal pain. A diagnosis of cervical radiculopathy does not comport with the chief complaints that do not include cervical or radiating extremity pain. There was no actual shoulder examination performed, and no referral to an orthopedist or neurologist who could diagnose and treat the patient's chief complaints using covered services. Billing for spinal manipulative therapy must be for a spinal complaint, and this was not the case with this patient.

According to Milliman Care Guidelines (MCG) 25th Edition, it is noted under "Spinal Manipulative Therapy" that only spinal complaints and treatment are covered services. These guidelines recognize spinal manipulation as a covered service only for spinal complaints, which was not the case for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation (AF)

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

Asked to review the case of a gentleman that presented to the hospital for elective catheter ablation of atrial fibrillation. Past medical history was significant for supraventricular tachycardia and previous ablation of a posteroseptal accessory pathway. He underwent left atrial catheter ablation and was discharged the following day. Of note, on induction of anesthesia the patient became hypertensive, and pupils were dilated. CT (computed tomography) scan of the head and neurologic evaluation were unrevealing, and the procedure was performed. Post procedure, the patient had mild, transient hypotension that resolved and was not associated with a pericardial effusion or bleeding elsewhere.

The health plan did act reasonably and with sound medical judgment and in the best interest of the patient. This patient presented to the hospital for an elective electrophysiologic (EP) study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post operative complications were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1) Bartolutti demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) In a report involving over 6000 patients, same day discharge following catheter ablation of AF was found to be safe and comparable to outcomes in patients that were observed overnight. (Reference 3) In conclusion, acute inpatient admission was not medically necessary in this case. 

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

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

Diagnosis: Mental Health/Attention Deficit Hyperactivity Disorder
Treatment: Occupational Therapy
The health plan denied the requested occupational therapy services. 
The health plan's determination is upheld.

This patient has a diagnosis of attention deficit/hyperactivity disorder.
Documentation available includes occupational therapy (OT) notes. Each of these is a brief subjective summary of the session. No information regarding patient's progress made in therapy at this time, goals, or standardized instruments documenting patient's performance compared to initial evaluation is included.
Phonological Processing comprehensive test administered was scored as average for Test of Word Reading Efficiency, Test of Reading Comprehension contextual fluency 2nd percentile, Curriculum-Based Assessment range of performance 19-30th percentile; Woodcock Johnson Tests of Achievement range of performance 18-53. Prescription from the patient's provider is for OT 2x (times)/week. Also available is Psychoeducational Assessment Education Update conducted, which documents that his phonological processing is at the expected range for his age, print reading fluency is intact, oral reading fluency is in 49th percentile, reading is at lower end of the expected range.
Areas of concern documented include decreased motor planning, fine motor and visual motor skills, postural control, safety during activities of daily living including dressing, feeding, and navigating the environment.
At issue is the medical necessity for Occupational Therapy plan of care and sessions.

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

The requested treatment is not medically necessary for this patient based on the information available.
Standard of care indicates that occupational therapy is medically necessary when there is documentation that it is improving a patient's current condition or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn, or improve skills and functioning for daily living to maintain the patient's current condition. In addition, the services must be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice. Skilled therapy is not medically necessary when the activities performed in therapy can be performed by non-skilled caregivers/parents who have received training by therapists, which is the case for this patient. Skilled therapy is not necessary when there is no documentation of the clinical necessity for therapy, goals of therapy, or evidence that patient is making progress towards goals.