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

Diagnosis: Choledocholithiasis. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the inpatient hospital stay. 
The health plan's determination is upheld. 

The patient is a female with a history of asthma who presented to the emergency department with right upper quadrant abdominal pain along with numbness of her right arm. The stroke team was activated and a computed tomography (CT) of the head occurred rapidly which did not demonstrate intracranial findings. Tele-neurology gave the patient a National Institute of Health Stroke Scale (NIHSS) of 1. The abdominal pain was colicky with radiation to the right shoulder. The patient had numbness going down the right arm after onset of the shoulder pain. The patient had associated nausea. The patient was found to be tender in the right upper quadrant. Her total bilirubin was 0.5 and her white blood cell count (WBC) was 5.8. 
The ultrasound of the abdomen demonstrated borderline common bile duct measuring 6 millimeters (mm) and the impression read that partially or completed occlusive choledocholithiasis could not be excluded. Acute cholecystitis was considered less likely. A magnetic resonance cholangiopancreatography (MRCP) was recommended. Gastroenterology was consulted who also recommended an MRCP. General Surgery also saw the patient and recommended an MRCP. The patient was hospitalized. The patient was noted to have had most of the pain subside and the nausea resolved. The MRCP demonstrated no common duct stones. The patient was noted to have epigastric pain and right upper quadrant (RUQ) pain after eating a chicken panini. The patient was noted to have RUQ tenderness. Her WBC was normal. The patient underwent a laparoscopic cholecystectomy without complication. 

The patient's admission was not medically necessary at the inpatient level of care for the entire admission. The patient did not demonstrate signs of systemic infection in association with the cholecystitis. The patient also did not demonstrate significant concern for cholangitis. The patient did not demonstrate hemodynamic instability. The patient did not demonstrate severe or persistent pain that would require high dose administration and monitoring. The patient did not demonstrate significant vomiting. The patient did not have signs of sepsis or bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level of care. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of inpatient level of care. 

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain in Left Shoulder. 
Treatment: MRI (magnetic resonance imaging) of the arm without contrast (73221). 
The insurer denied: MRI of the arm without contrast (73221). 
The denial is upheld. 

This patient is an adult male with a painful left shoulder. He was seen 10 months ago and reported numbness and tingling down his arm. The physical examination was significant for being normal. The X-ray (electromagnetic radiation) report showed no acute abnormality. The physician recommended magnetic resonance imaging (MRI) to the left shoulder. This was completed 9 months ago. It showed tendinosis and atrophy. Physical therapy was provided 8 months ago. 

The requested health service is not medically necessary. 

The criteria for magnetic resonance imaging had not been fulfilled. Magnetic resonance imaging is indicated if additional information is necessary to provide special service. Magnetic resonance imaging should not be completed unless a course of conservative treatment has been provided. The records showed an initial consultation, and then subsequent magnetic resonance imaging. There was no indication that surgery may have been necessary. There were no extenuating circumstances to support the need.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis

Treatment: Otezla

The insurer denied coverage for Otezla.

The denial is overturned.

The patient has a diagnosis of psoriasis and seborrheic dermatitis. The patient has mild-moderate disease with approximately 5% (percent) total body surface area (TBSA), including involvement of the scalp and face.  The patient has failed therapy with topical steroids, ketoconazole, and Elidel.  Given involvement of the face and scalp, treatment options are limited.  Of note, the patient's disease is mild with involvement of the face and scalp requiring systemic therapy.  The requested medication is Otezla.      

Based on the submitted documentation, the use of Otezla is medically necessary.  The patient has mild to moderate psoriasis affecting the scalp and face. The involvement of these areas makes the use of high-potency steroids challenging. Otezla is Food and Drug Administration (FDA) approved for mild psoriasis, such as this case.  Requested formulary alternative systemic agents are not FDA approved for the treatment of psoriasis and are not commonly used to treat mild disease. Calcipotriene and coal tar are not likely to be clinically more effective than already tried and failed topical steroids and Elidel.  Otezla is the most appropriate systemic therapy for mild psoriasis and has an FDA indication for mild and moderate psoriasis (5). The patient has failed reasonable alternatives.  The use of alternative systemic agents, such as methotrexate, cyclosporin, or biologics, are generally reserved for more moderate to severe disease.  The use of Otezla is approved for use in the management of the patient's psoriasis based on the standard of care.

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

The medical necessity for Otezla is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cough/difficulty breathing
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is an infant female infant born at term who was taken to the emergency department (ED) via Emergency Medical Services (EMS) with five-day history of productive cough with clear to green nasal discharge, and one-day history of increased work of breathing with abdominal breathing. There were no fevers. Even though feeding had not changed, there were decreased wet diapers. Vital signs included temperature 36.7 degrees Celsius (oC), heart rate 148, and respiratory rate 34 with 100 percent (%) saturation in room air. Examination was significant for non-ill appearance, adequate tear production, moist mucous membranes, nasal congestion with clear to green discharge, tachypnea, abdominal breathing, transmitted upper airway sounds, benign abdomen, and non-focal neurologic exam. 

The inpatient hospital admission was not medically necessary. This young female infant with unremarkable medical history presented with signs and symptoms consistent with viral bronchiolitis. She was treated with nebulized saline to assist with suctioning. She was treated with nebulized albuterol without benefit. While it was reasonable to monitor her in the hospital for improvement versus decompensation (she was in fact admitted for observation), she was overall hemodynamically stable, able to feed as usual, with no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot pain/swelling. 
Treatment: Inpatient stay. 
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a man with a history of diabetes, hypertension, osteomyelitis, and toe amputation. He presented to the emergency room with right foot discoloration and swelling. He was evaluated about one week ago by his PCP (primary care provider) who was concerned about osteomyelitis, and started the patient on oral antibiotics, and ordered an magnetic resonance imaging (MRI) which has not yet been completed. Vital signs included a blood pressure of 172/89 and a pulse of 102. He was in no acute distress. Physical exam revealed an amputate right 1st toe swelling and ecchymosis of the plantar surface of the right foot. 

The inpatient admission was not medically necessary for this patient. 
Upon presentation, there was no objective evidence on physical exam, labs, or imaging of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, persistent hypoxia, or severe metabolic disarray. A soft tissue infection and/or osteomyelitis was not found, and there was no vascular compromise. The services provided - intravenous antibiotics, oral medications, debridement (without anesthesia - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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


This is a female patient who presented to the emergency department (ED) complaining of worsening anxiety, depression and panic attacks with palpitations and chest pain. She also reported frequent urination. Her medical history was remarkable for morbid obesity and frequent premature ventricular complexes (PVCs). An electrocardiogram showed sinus rhythm with frequent monomorphic premature ventricular contractions (PVCs) in a bigeminal pattern. The PVCs had a left bundle branch block morphology with an inferior axis. There were no acute ischemic changes. Her serum troponin level was normal.
She was admitted to the hospital for further evaluation of her PVCs.  At issue is the medical necessity of an inpatient stay.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with anxiety, depression and panic attacks with palpitations and chest pain. She was admitted to the hospital when an electrocardiogram showed frequent premature ventricular complexes (PVCs). She was hemodynamically stable, without evidence of acute ischemia or decompensated heart failure. An echocardiogram showed a structurally normal heart. The morphology of the PVCs suggested an outflow tract site of origin. PVCs in patients with structurally normal hearts are typically benign, particularly when originating in the right or left ventricular outflow tract. No particular treatment was required for this patient's arrhythmia during her hospitalization. Thus, her frequent PVCs alone did not require an inpatient level of care.
The patient had an abnormal exercise stress test with chest pain, frequent PVCs and a drop in her blood pressure immediately post-exercise. However, there were no significant ST segment changes, outflow tract PVCs are typically induced by exercise and her blood pressure recovered to her pre-test level within 30 seconds. While it was reasonable to suggest coronary angiography or a stress echocardiogram, this did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic neck pain

Treatment: Pain injections (64490 x 1, 64491 x 1)

The insurer denied coverage for pain injections (64490 x 1, 64491 x 1)

The denial is overturned

This patient has chronic neck pain. The patient has had Physical Therapy (PT) and is doing a home exercise program. The patient's medication trials include Tylenol, Robaxin, Flexeril and Gabapentin. A magnetic resonance imaging (MRI) shows C (cervical) 6-C7 herniated disc, Spondylosis at C5-C6 and C6-C7 with neuroforaminal stenosis. The patient had trigger point injections with good effect. The plan is for 2 sets of diagnostic medial branch blocks.

Clinical practice guidelines (1) support this approach to diagnosis:

The criterion standard of 80% (percent) pain relief was utilized in 4 studies in 1,802 patients that showed a prevalence ranging from 27% to 40% in a heterogenous population. All the patients assessed with 80% pain relief criterion standard were by Manchikanti and colleagues. They utilized the standard of chronic pain with relief lasting beyond pharmacological duration of action of the local anesthetic for both lidocaine and bupivacaine. Further, Manchikanti et al also utilized lidocaine the short acting local anesthetic initially followed by bupivacaine in the longer-acting anesthetic in all the studies. The evidence for accuracy of lumbar facet joint nerve blocks is Level I to II based on 10 diagnostic accuracy studies with 4 studies utilizing >(greater then) = (equal) 80% criterion standard of pain relief with a prevalence rate of 27% to 40% with false-positive rates of 27% to 47%, with moderate to strong strength of recommendation.

The Health Plan suggested that the patient hasn't had imaging, PT and medication therapy. All of these are clearly documented in the patient's record.  Diagnostic blocks are supported by clinical practice guidelines and are the next step.

The requested procedure is medically reasonable and necessary.  

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

The medical necessity for pain injections (64490 x 1, 64491 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic musculoskeletal pain.
Treatment: Durable medical equipment (DME), K0800 x 1.

The insurer denied coverage for durable medical equipment (DME), K0800 x 1.  The denial is upheld.

This is a patient complaining of chronic musculoskeletal pain. The patient lives on the 4th floor in an elevator accessible apartment. The patient underwent a right sub-trochanter fracture repair, subsequent hardware removal and residual chronic pain. The patient also reports chronic knee, back and foot pain. Under review is the requested durable medical equipment (DME) K0800 x 1.

The clinical notes submitted for review do not support the medical necessity of the requested motorized device. The patient is fully ambulatory and functionally independent. The more recent office visit notes "Telemedicine Video Visits" submitted for review are reviewed. The patient complains of chronic musculoskeletal pain. However, there are no focal motor deficits, and gait is consistently documented as "normal." There is no documented evidence of a specific impairment supporting the medical necessity of the requested DME K0800 x 1.

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, DME K0800 x 1 is not medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for durable medical equipment (DME), K0800 x 1 is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic Congestion Syndrome. 
Treatment: Ovarian and internal iliac vein embolization. 
The insurer denied coverage for ovarian and internal iliac vein embolization. 
The denial is upheld. 

The patient has pelvic congestion syndrome recommended treatment with ovarian and internal iliac vein embolization. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

Use of this treatment, ovarian and internal iliac vein embolization is not supported by peer reviewed data, and has not been studied via large, prospective studies and it has not been shown to improve health outcomes in patients with pelvic congestive syndrome. 

"Pelvic congestion syndrome (PCS) is a common cause of chronic pelvic pain in women of reproductive age. Pain that is intermittent or constant lasting for 3-6 months, present in the pelvic or abdominal region, occurring throughout the menstrual cycle, and without any association with pregnancy is chronic pelvic pain... Medical management should be the first-line treatment for PCS. This is due to decreased complications of medical management as compared to invasive procedures. Gonadotropin-releasing hormone (GnRH) agonists, danazol, combined oral contraceptives, progestins, phlebotonics, and non-steroidal anti-inflammatory drugs are a few treatment options that have shown effective management for the pain in PCS. Etonogestrel implant, goserelin, and medroxyprogesterone acetate have also been successful in alleviating the pain associated with PCS. Improved pain relief is observed when medroxyprogesterone is given along with psychotherapy. Goserelin, a GnRH agonist, has better results in controlling the pain as compared to medroxyprogesterone acetate, but it cannot be continued beyond 1 year due to it being a GnRH agonist" (Saadat Cheema, O., & Singh, P. 2022). 

Use of this procedure has not been approved by the appropriate regulatory bodies. 

This patient is not a good candidate for ovarian and internal iliac vein embolization. 

There are no data to support this treatment for this patient. 

Ovarian and internal iliac vein embolization is not the best available treatment for this patient at this time. 

Use of this treatment has not been shown to improve outcomes and it is not standard of care or supported by medical evidence. 

Use of this treatment could result in lower perfusion to pelvic organs. 

This treatment is not likely to be more beneficial than any of the standard treatments / procedures for this patient. 

In summary, the denial of ovarian and internal iliac vein embolization and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic Congestion Syndrome. 
Treatment: Ovarian and internal iliac vein embolization. 
The insurer denied coverage for ovarian and internal iliac vein embolization. 
The denial is upheld. 

The insurer has denied coverage for ovarian and internal iliac vein embolization. In their Final Adverse Determination letter, they write that the patient has growths within their womb. They write that based on the information provided the criteria are not met because the role of this service remains uncertain. It is not proven that it improves health outcomes over usual standard care. The insurer writes that the health plan does not cover experimental or investigational treatment.  

Pelvic congestion syndrome (PCS), also known as chronic pelvic pain syndrome or pelvic venous incompetence, is caused by utero-ovarian varices. PCS is defined by engorged pelvic veins of more than 10 millimeter (mm) diameter on selective transuterine venography in multiparous, premenopausal women with a history of chronic, noncyclic pelvic pain for more than six months. 

Up to 15 percent of premenopausal women have pelvic varicosities and venous stasis, as demonstrated by pelvic venography, but few experience symptoms. Pelvic congestion syndrome is the term used to describe the subset of these women who have pain and other symptoms in the uterus, ovaries, and vulva that cannot be attributed to any other cause. 

Although this diagnosis remains controversial, there is evidence that some women with pelvic varicosities and venous stasis, as demonstrated by pelvic venography, have associated chronic pelvic pain. 

The procedure 37241 x 1, closing of blood vessels in the pelvis is not considered more beneficial for this patient's diagnosis. 

1.	The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 
2.	Ovarian and internal iliac vein embolization does not need final approval from the appropriate regulatory bodies for this diagnosis. 
3.	Due to lack of scientific evidence of health improvement, it is unknown if this patient is a good candidate for ovarian and internal iliac vein embolization. 
4.	Ovarian and internal iliac vein embolization is not the best available treatment for this patient at this time. 
5.	The adverse risks are increased over standard treatment/services. 
6.	The requested service is unlikely to be more beneficial than any of the standard treatments/procedures for this patient. 

In summary, the denial of ovarian and internal iliac vein embolization and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Formulary Exception
Decision: Upheld

Mental Health
Pharmacy/Prescription Drugs

Diagnosis: Attention Deficit Hyperactivity Disorder/ADHD
Treatment: Vyvanse 20MG capsules
The health plan denied: Vyvanse 20MG capsules
The determination is: Upheld 

The patient is a male being prescribed Vyvanse 20 milligram (mg) capsules for the diagnosis of attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type.
The patient's physician assistant provided a letter of support for this appeal. The letter states that the patient was previously prescribed Adderall by another physician. The patient did not tolerate this medication at all, experiencing anxiousness, loss of appetite, and insomnia. The prescriber states that a trial of the requested medication, Vyvanse, is more appropriate for the patient given its pharmacologic profile.

A formulary exception is not indicated in this case. There is insufficient evidence that the available formulary drugs would be ineffective, less effective than the requested drug, or would have adverse effects.
Clinical guidelines for the management of attention-deficit hyperactivity disorder recommend consideration of stimulants as pharmacologic options, but they do not place preference for the requested medication over the available formulary alternatives. The patient had a trial of Concerta and Adderall XR, but there are other covered formulary alternatives available to treat the patient's ADHD. These medications include atomoxetine, generic Dexedrine spansule, and generic Focalin XR.