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

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

This is a patient with no past medical history. Patient presented to emergency department with complaint of left back pain radiating to left testicle for the past 3 days. Patient had been to same emergency room and computed tomography scans on both visits revealed a 3 millimeter (mm) ureteral calculus and 2.7 centimeter (cm) left renal cyst. Patient was treated in emergency department and admitted to medicine for a possible urologic procedure. The patient felt that he passed his stone overnight, pain resolved, and he was discharged home. The insurer has denied coverage for the inpatient admission as not medically necessary. They stated the patient did not meet InterQual 2021 Acute Adult General Medical, Genitourinary (GU) criteria. They stated there was not documentation of sudden injury to kidneys, urinary obstruction, swollen kidneys, or excessive proteinuria. The appeal on behalf of the hospital is noted and read in detail. 

The inpatient admission is not considered medically necessary for this patient. Per InterQual 2021 Acute Adult general medical, GU criteria patient fails to show evidence of acute kidney injury (AKI), GU obstruction, or hydronephrosis: renal sonogram was negative for any hydronephrosis. No elevated temperature noted. Patient passed his stone presumably overnight. No evidence of renal failure or need for continuous analgesics.

The health care 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: Overturned

Diagnosis: Disorientation, dysarthria, and weakness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a woman with past medical history of hypertension, hyperlipidemia and recent diagnosis of pericardial effusion. She presented to the emergency room due to sudden onset disorientation, dysarthria, and left facial/arm/leg weakness which subsequently improved upon arrival to emergency room.

The patient was noted to be hypertensive with blood pressure of 218/100. She was noted to be bradycardic. CT (computed tomography) head and CTA (Computed Tomographic Angiography) head and neck did not show acute changes. She received IV (intravenous) fluids and aspirin. tPA (tissue plasminogen activator) was not given. She was admitted to evaluate for transient ischemic attack and to rule out a stroke. Neurochecks were performed every 2 hours for 4 hours, which were gradually spaced out further. Brain MRI (magnetic resonance imaging) did not show acute stroke.

Coverage for the inpatient admission was denied by the health plan as not medically necessary. The denial is being appealed.

Yes, the Inpatient admission was medically necessary.
According to the MCG (Milliman Care Guidelines) guidelines, inpatient admission is warranted when there is need for prolonged cardiac telemetry monitoring. Furthermore, the patient had hypertensive emergency related to the transient ischemic attack, and the blood pressure needed to be monitored and gradually decreased. This could not have been done in the outpatient setting.

Therefore, given the above, the Inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient met MCG (Milliman Care Guidelines) guidelines for inpatient admission due to the need for prolonged telemetry monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric pain, abdominal bloating, history of
regurgitation.
Treatment: Esophagogastroduodenoscopy (EGD) (43239). 
The insurer denied the Esophagogastroduodenoscopy (EGD) (43239) .
The denial is overturned.

The patient is a male. The denial letter indicates that the endoscopy did not meet the clinical criteria per the policy titled, Upper Gastrointestinal Endoscopy in Adults, Guideline #: CG-MED-59.

A clinic note indicates that the patient presented with epigastric pain, abdominal bloating and history of regurgitation, consistent with new onset dyspepsia. An esophagogastroduodenoscopy (EGD) was done and showed mild gastritis. Biopsies were taken.

Yes, the proposed esophagogastroduodenoscopy (EGD) (43239) performed was medically necessary.
Based on a joint American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guideline for dyspepsia, "We suggest that patients 60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology."

Per the documentation, a clinic note indicates that the patient had new onset epigastric pain and fullness consistent with dyspepsia diagnosis.  Thus, it is consistent with the aforementioned guideline to perform the proposed testing given the patient's age at the time it was done.

No, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The coded diagnosis in the endoscopy report is epigastric pain.  The patient's presentation was consistent with dyspepsia based on the clinical documentation. Testing was deemed medically necessary based on standard of care guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain.
Treatment: Neurostimulation Device. 
The insurer denied: Neurostimulation Device.
The denial is overturned.

The patient is an adult female with chronic low back pain (7-10/10 pain) not responsive to conservative management (six months of physical therapy, TENS (transcutaneous electrical nerve stimulation), medication management with NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, and opioids, and interventional injections - thoracic and lumbar medial branch blocks and radiofrequency ablations and sacroiliac joint injections). Lumbar spine intervention is not indicated. Her treating provider diagnosed her with chronic low back pain secondary to dysfunction of the lumbar multifidus muscles confirmed by multifidus atrophy seen on an MRI (magnetic resonance imaging) of the lumbar spine from 3 years ago. Her treating physician recommended the Reactiv8 procedure; however, the procedure was denied coverage by the health plan due to it being considered experimental/investigational. The denial is being appealed.

The health plan should cover the proposed treatment.

The patient has tried and failed the indicated standard treatments, such as six months of physical therapy, TENS (transcutaneous electrical nerve stimulation), medication management with NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, and opioids, and interventional injections - thoracic and lumbar medial branch blocks and radiofrequency ablations and sacroiliac joint injections.

The Reactiv8 procedure is FDA (United States Food and Drug Administration)-approved, and there is enough data in the medical literature to show it is safe and effective in the treatment of refractory chronic low back pain secondary to multifidus dysfunction. The procedure has level I evidence supporting it as appropriate.

A prospective, multi-center study by Gilligan et al in 2021, the follow-up study again by Gilligan et al in 2022 (multicenter prospective trial), and a single arm prospective trial by Mitchell et al showed that the Reactiv8 procedure was effective (reduced pain, improved function and quality of life at 2 years and 4 years and reduced opioid reduction by 60% at 2 years). Also, the studies demonstrated the procedure was safe. Lastly, the Reactiv8 procedure is not subject to a phase I or II clinical trial, it is not being offered to patient as part of a clinical trial, and it is not subject to an independent review board (IRB).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain.
Treatment: Neurostimulation Device. 
The insurer denied: Neurostimulation Device.
The denial is upheld.

The patient is an adult female with low back pain and knee pain. Pain medications have included Flexeril, Neurontin, and Cymbalta. The patient has tried medical branch blocks and radiofrequency ablation at bilateral L3-S1 and bilateral T11-12, sacroiliac joint injections, and knee injections. X-ray of the lumbar spine shows mild degenerative change without abnormal motion on flexion/extension. MRI (magnetic resonance imaging) of the lumbar spine shows mild lumbar degenerative change and mild disc bulge without significant stenosis. The request for peripheral nerve stimulation at the L2 medial branch to improve multifidus muscles in the form of motor stimulation was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the Neurostimulation Device.

There is insufficient or inconclusive evidence published in peer-reviewed medical literature to evaluate the therapeutic value. There are no well-designed and well-conducted studies. There is inconclusive evidence published in peer-reviewed medical literature that the service improves net health outcomes. The services' beneficial effects on health outcomes does not outweigh any harmful effects on health outcomes. The service under consideration is not as beneficial as any established alternatives. Small, published case studies do demonstrate the significance of peripheral stimulation as an innovative approach to treat chronic pain, however, more studies are needed to substantiate its effectiveness and safety. As such the requested service is unproven or experimental/investigational (E/I).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain.
Treatment: Neurostimulation Device.
The insurer denied: Neurostimulation Device.
The denial is upheld.

The patient is an adult female with chronic back pain in whom an implantation of a peripheral nerve stimulator (PNS) has been recommended. Specifically, Reactiv8 is requested, which is a multifidus muscle stimulator. She has failed PT (physical therapy), home exercise, medications, and injections. PE (physical examination) shows multifidus muscle instability. The procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the Neurostimulation Device.

The patient is an adult female with chronic back pain in whom an implantation of a peripheral nerve stimulator (PNS) has been recommended. Specifically, Reactiv8 is requested, which is a multifidus muscle stimulator. The patient has failed PT (physical therapy), home exercise, medications, and injections. PE (physical examination) shows multifidus muscle instability.

The requested procedure is not a commonly accepted treatment for this condition and has not been shown to be effective in the treatment of chronic low back pain as shown by high quality randomized control trials (RCT). There is a randomized controlled trial in the setting of chronic pain following amputation, but not this condition. These pathologies are quite different. Other case reports, and observational studies show some benefits in other pain conditions. Other more proven, conventional treatments have been shown to be superior in the literature, such as spinal cord stimulation. Some recent data has shown it may be effective as add on therapy to spinal cord stimulation (SCS), but not as a standalone therapy. Given the lack of data to support an invasive procedure for this type of condition, the requested PNS (peripheral nerve stimulation) is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient presented to the emergency department (ED) complaining of chest pain, dyspnea and orthopnea. His medical history was remarkable for non-ischemic cardiomyopathy, heart failure with reduced ejection fraction (25-30% [percent]), hypertension, chronic kidney disease, obesity, polysubstance abuse and non-ST segment (region between the end of ventricular depolarization and beginning of ventricular repolarization on the electrocardiogram) elevation myocardial infarction attributed to substance abuse. 

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient was admitted to the hospital for management of decompensated heart failure. He was hemodynamically stable and did not have high risk features, such as tachycardia, systolic blood pressure less than 100, hyponatremia or acute kidney injury. While his serum troponin level was mildly elevated, there was no significant delta troponin. His symptoms improved promptly with intravenous furosemide. Based on his Emergency Heart Failure Mortality Risk Grade score, his 7-day mortality risk was low. In stable heart failure patients, such as this man, without high risk features, studies have shown that observation is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, a lower level of care would have been sufficient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent 300MG (milligrams)/2ML (milliliters) SC 
(subcutaneous) SOSY (Solution Prefilled Syringe).
The insurer denied: Dupixent 300MG (milligrams)/2ML (milliliters) SC 
(subcutaneous) SOSY (Solution Prefilled Syringe).
The denial is overturned.

The patient is an adolescent female diagnosed with moderate to severe atopic dermatitis and has tried and failed triamcinolone and Eucrisa. She was started on Dupixent 2 years ago and has had a positive response.  The treating provider is requesting coverage for continuation of Dupixent, but this was denied by the plan stating that the request was not medically necessary since the patient did not have a trial of the plan alternatives. The treating provider is appealing the denial.

The proposed Dupixent is medically necessary.

Dupixent is Food and Drug Administration (FDA) approved for patients six months and older with moderate to severe atopic dermatitis who have failed topical therapy.  This patient has been stabilized on Dupixent after failing topical therapy with triamcinolone and Eucrisa.  To disrupt the current effective treatment for a trial of inferior topical therapy or off-label use of systemic treatment puts the patient at risk for destabilization and is not standard of care.  Senner S et al (2020) writes. "Dupilumab was approved by the Food and Drug Administration in March 2019 and by the European Medicines Agency in August 2019 for the treatment of adolescents with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical therapies or when those therapies are not advisable. Since it is the first licensed drug it will likely become the reference drug for adolescents with moderate to severe AD."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain.

Treatment is an inpatient admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is upheld.

The patient presented with vomiting and abdominal pain. She had a history of endometriosis, IBS (irritable bowel syndrome), and chronic leukocytosis. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The White Blood Cell (WBC) count was 29.3. The renal function was normal. An abdominal CAT (computed tomography) scan was negative for acute findings. She was diagnosed with THC (Tetrahydrocannabinol) induced cyclic vomiting. IV (intravenous) fluids, proton pump inhibitor (PPI) therapy, and antiemetics were given. She improved with treatment. 

Clinical indications for admission for Vomiting (MCG (Milliman Care Guidelines) M-370) include having a significant metabolic derangement such as ketoacidosis, hemodynamic instability, severe vomiting that is not responsive to antiemetics, severe electrolyte abnormalities, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

This patient presented with vomiting that was likely secondary to cannabinoid use. IV hydration, PPI therapy, and antiemetics could have been given with observation care. The leukocytosis was a chronic problem. She improved with treatment. She did not meet Milliman Care Guidelines (MCG) criteria for admission for either Vomiting or Undiagnosed Abdominal Pain. 
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: Parkinson's

Treatment is continued stay in the rehabilitation center

The insurer denied coverage for continued stay in the rehabilitation center
 
The denial is upheld

This is a male patient, who has a history of paranoid schizophrenia, Parkinson's, seizures, substance abuse, and deep vein thrombosis. He was admitted to a rehab center with decline in mobility, function, and self-care ability. He is now medically stable. 

The patient is now mostly contact guard assist (CGA)-to-supervised for care. The patient has no complex wound care needs, or intravenous (IV) medication requirements. There are no nursing or therapy needs that are skilled and warranting a continued stay in the rehabilitation center as opposed to a lesser level of care (including home health care services). The patient's vital signs are stable. As such, the continued stay in the rehabilitation center is not considered medically necessary for this patient.

"Individuals with health conditions or injuries may require rehabilitation across the course of their lifespan. The timing and type of intervention that a rehabilitation provider selects depend greatly on several factors. These include the etiology and severity of the person's health condition, the prognosis, the way in which the person's condition affects the person's ability to function in the environment, as well as the individual's identified personal goals. Rehabilitation services may be delivered in any setting (including in hospitals and in communities), depending on individuals' needs and situation. " (Mills, T. et al 2017).

O'Brien, S. R., & Zhang, N. (2018) state "High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95). High intensity therapy was associated with desirable discharge outcomes and may shorten SNF (skilled nursing facility) length of stay" 

The continued stay in the rehabilitation center is not considered medically necessary for this patient. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 
                                                       
The insurer's denial of coverage for continued stay in the rehabilitation center is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Cancer
Treatment: Proton beam radiation therapy
The insurer denied: Proton beam radiation therapy
The denial is: Overturned

This patient is a female with a history for a left breast carcinoma post chemotherapy and radiation therapy. She has had extensive metastatic disease treated with surgery and systemic therapies. She now has leptomeningeal carcinomatosis where craniospinal radiation therapy is recommended for palliation and proton beam approach is requested. The subject under review is the medical necessity for the requested proton beam therapy.

The health plan's determination is overturned.

The requested health service/treatment of proton beam radiation therapy is considered medically necessary for this patient.

This patient has had previous radiation to the left breast that extended to midline. The recommended craniospinal radiation therapy is medically appropriate for this patient and her metastatic disease. The use of proton beam radiation therapy is this clinical scenario would be considered medically appropriate and necessary as it has been shown to have improved normal tissue sparing in previously irradiated regions in a patient such as this. There are also very good studies published in peer reviewed journals supporting the use of proton beam radiation therapy for craniospinal irradiation as proton beam radiation has physical characteristics called the Bragg peak that can improve the volume of critical vital structures adjacent to the target volume from receiving high doses of radiation and thus decrease the risk of side effects. For this patient comparison radiation plans were completed between proton radiation and photon beam radiation where it was shown from dose volume histograms that there was significant improvement of these high dose regions with protons as compared to photon beam radiation. The use of protons for craniospinal irradiation and reirradiation are supported by American Society for Radiation Oncology (ASTRO) clinical guidelines as well as National Comprehensive Cancer Network (NCCN) Guidelines with category 2a support.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Genetic testing (code: 81256)
The insurer denied the genetic testing.
The denial is upheld. 

The requested Genetic Testing (code: 81256) was not medically necessary.
The patient is a female. At issue is HFE (homeostatic iron regulator) mutation testing. Iron studies done that day were notable for a ferritin of 82 and iron saturation
of 15%.
This patient was found to have a normal ferritin and reduced iron saturation. These results are not indicative of iron overload or possible hereditary hemochromatosis. Iron saturation is a validated screening test for hereditary hemochromatosis, and elevation in iron saturation suggests the possible presence of hemochromatosis. Reduced iron saturation is not indicative of likely hemochromatosis. Given that there were no findings based on iron studies indicating possible iron overload, the HFE (homeostatic iron regulator) gene mutation testing done in this case was not medically necessary.