Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose Veins. 
Treatment: Ovarian vein ablation (procedure code 37241 times 1 unit). 
The insurer denied the ovarian vein ablation (procedure code 37241 times 1 unit) as experimental/investigational (E/I). 
The health plan's determination is overturned. 

The patient is a female with varicose veins of the pelvis for a long time which are symptomatic. Imaging by computed tomography (CT) confirms findings which noted prominent varicose pelvic veins, enlarged left ovarian vein and a left common iliac vein abnormality. There is also a circumflex aortic left renal vein. 
Her pain is significant and her quality of life is poor. She is in good overall health. Her medications were reviewed. No surgery was planned. Treatment has been unsuccessful to date. Her past medical history was reviewed and pertinent past medical records were reviewed. 
The current treatment plan would be pelvic and ovarian bilateral venography with intravascular ultrasound (IVUS) and venous embolization as required. There also may be need for iliac venous treatment with stenting or angioplasty. 

The proposed health service or treatment 'Ovarian/Gonadal ablation, known also as Ovarian Vein Embolization', is likely to be more beneficial than any other standard treatment for this insured's disabling condition/disease. The proposed treatment based on present scientific data, has been proven to be safe and effective for the diagnosis given of symptomatic pelvic venous malformations. The patient in question has confirmed abnormalities of her pelvic veins. 

Pelvic venous incompetence can be a terribly disabling diagnosis and a medical problem that should not be ignored but rather requires a meaningful treatment attempt. This should not be considered experimental or investigational. To treat the patient's condition by performance of this minimally invasive approach, mainly with venous embolization, will lessen her varicosities and improve her symptoms. 

The health plan's determination is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins. 
Treatment: Ovarian vein ablation (procedure code 37241 times 1 unit). 
The insurer denied the ovarian vein ablation (procedure code 37241 times 1 unit) as experimental/investigational (E/I). 
The health plan's determination is upheld. 

The patient is a female with pelvic pain and a computed tomography (CT) scan showing left ovarian vein dilation and pelvic varices. The provider wishes to perform ovarian vein embolization and possible left iliac stent placement for suspected pelvic congestion syndrome. 

There is lack of peer-reviewed literature supporting a better outcome with ovarian vein embolization for possible pelvic congestion syndrome compared with other standard medical treatments. The body of evidence in the peer-reviewed medical literature regarding embolization of the Ovarian Vein or Internal Iliac Veins for the treatment of pelvic congestion syndrome (PCS) is insufficient and poor quality. While some studies suggest favorable results of embolization for the treatment of PCS, additional well-designed randomized controlled trials are necessary to establish the relative safety and efficacy of the embolization procedure. 

The health plan's determination regarding the proposed health service or treatment is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins. 
Treatment: Ovarian vein ablation (procedure code 37241 times 1 unit). 
The insurer denied the ovarian vein ablation (procedure code 37241 times 1 unit) as experimental/investigational (E/I). 
The health plan's determination is overturned. 

The patient is a female with pelvic pain severely limiting quality of life. She describes painful intercourse and low libido. Imaging suggests the presence of significantly dilated ovarian veins, compressed renal and iliac vein. These symptoms and imaging findings are consistent with the described and established syndrome of pelvic congestion. 

The vascular embolization procedure is a well-established nonexperimental highly effective treatment option for patients that have dilated pelvic congestion syndrome. The embolization procedure for this patient is the most appropriate and really the only available treatment option given her symptoms and imaging findings. This procedure is well described. Over the past two decades have been many papers that have been written on this procedure its application and effectiveness for this condition, this would confirm that this is an evidence based treatment option that is the standard of care for this condition. 

The health plan's determination regarding the proposed health service or treatment is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Presyncope and vomiting

Treatment: Magnetic Resonance Imaging (MRI)

The insurer denied coverage for MRI

The denial is upheld

 
This case pertains to an adult female and review of denial of repeat MRI of the head. 

The patient presented with complaints of presyncope and vomiting. She has a known history of schizophrenia and diabetes mellitus and was referred for neurological evaluation due to her presyncope. She reports one episode of suddenly unable to feel her body along with vomiting 4-5 times that evening. Current medications include Olanzapine 15 milligrams (mg), Depakote 500mg, Steglatro 5mg, Glipizide extended release (ER) 2.5mg, Vitamin B12, and Metformin 500mg, Jardiance 10mg. Her physician ordered Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of brain without contrast dye, echocardiogram, electroencephalogram (EEG), and carotid doppler. Electrocardiogram (ECG) found normal sinus rhythm, consider right atrial enlargement but otherwise normal, EEG was normal. Carotid Doppler was unremarkable. 

MRA of the intracranial arteries was unremarkable. The MRI of the brain was unremarkable. 

The patient presented for follow-up to review imaging. MRI and MRA exams were unremarkable, EEG was unremarkable, carotid doppler was unremarkable. Glucose was 118, glycated hemoglobin was 6.0, with the remainder of labs essentially within normal limits. Neuro examination noticed mild right facial droop. Suspect possible vestibular migraines versus atypical seizures. Her symptoms may also be related to her known Sjogren's disorder. Advised to follow-up with cardiologist to rule out cardiac arrhythmia. Will start trial of Topamax 25mg twice a day(BID) with titration to 50mg BID for headache and seizure prevention.  No further testing was ordered by her doctor.

The insurer sent a letter to the patient denying request for MRI of head. They noted that a study like the one she requested had already been done. There was no documentation suggesting the need for repeat imaging.

The provider sent a letter noting the patient was under his care. He ordered MRI/MRA brain, carotid doppler, and EEG as part of necessary work up of her neurological complaints. These studies were performed after insurance approval. A second MRI was not ordered.

There is not a medical necessity for another MRI of the head as the MRI of the brain done on an earlier date was unremarkable. There is no indication for repeat imaging when previous imaging was normal. This is likely a duplicate request . The provider did not substantiate the need for any other imaging. 

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 procedure code 70551, a duplicate request, magnetic resonance imaging (MRI), a special kind of picture of the head without dye services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: New-Onset Diabetes 
Treatment: Inpatient Hospital Stay

The insurer denied the inpatient hospital stay.

The determination is overturned.

The patient is a female with lupus on prednisone, Cellcept, hydroxychloroquine, and famotidine, who was referred for hospitalization by her rheumatologist for initiation of insulin therapy for new-onset diabetes. She had been seen the day before in the rheumatology clinic; blood work done at that time later returned with a glucose greater than 600. She did not have ketones. She did have symptoms of diabetes, polyuria, and polydipsia but was otherwise stable. Her vital signs were normal on arrival. She entered the new onset diabetes teaching program so that she and her family could learn about glucose blood measurements, urine dipsticks, carbohydrate counting, insulin sliding scales, and the safe administration of insulin shots. After successfully completing the education program, the patient was discharged and allowed to go home. At issue is the medical necessity of an inpatient stay. 

The inpatient hospital admission was medically necessary. Management of new-onset diabetes in children and the initiation of insulin therapy varies by region and by medical centers within a region. Before the 2000s, it was uniformly standard for patients with new onset diabetes to be admitted to the hospital, not just for acute diabetes management but also for the extensive teaching required to begin insulin at home safely. In the past 20 years, there has been an increasing trend toward performing this education as an outpatient if the patient is clinically stable and not in ketoacidosis. The literature focuses on the comparative safety and efficacy of outpatient versus inpatient therapy rather than on the standard of care.

Many centers do not have outpatient educational training resources, and hospitalization for new-onset diabetes remains the standard of care for these centers. Even at centers that do have outpatient teaching resources, decisions to admit are also individualized based on comorbidities. The reason for admission is to normalize the blood sugar and craft a patient-specific management plan for diet, exercise, carbohydrate counting, urine and blood testing, and insulin administration (at home and possibly school). Both the child and parent/caregiver(s) require the education. This patient was clinically stable but did have lupus under treatment with three medications that complicated planning her diabetes care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysmenorrhea and bilateral hydrosalpinx
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female who underwent a laparoscopic bilateral salpingectomy, lysis of adhesions, left ureterolysis, and cystoscopy secondary to dysmenorrhea and bilateral hydrosalpinx. She was admitted as inpatient. She had a fever of 102.1 degrees Fahrenheit (F) and was started on antibiotics. She was discharged the following day. The inpatient admission is under review for medical necessity.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.
The patient is a female who underwent an elective laparoscopic procedur.. She had a postoperative fever and was given antibiotics however no other fever was noted and she did well after surgery. Her other vital signs were normal and she had no hemodynamic instability. Her procedure was without complications and she had no further postoperative complications. She had no anesthesia complications. She could have been observed after surgery in the post-anesthesia care unit (PACU) or at a lower level of care as she was discharged less than 24 hours later. There was no need for acute, inpatient monitoring as there was no continuing complications after surgery. She had no hemorrhage nor poor wound healing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left shoulder pain.
Treatment:  Shoulder MRI (Magnetic Resonance Imaging) - pictures of inside your shoulder, Visits/Units requested: 1.

The insurer denied coverage for shoulder MRI (Magnetic Resonance Imaging)- pictures of inside your shoulder, Visits/Units requested: 1.  The denial is upheld.

This is an adult with left shoulder pain. He was noted to have pain with raising his arm to 90 degrees. He was referred for Magnetic Resonance Imaging (MRI) of the left shoulder. It was denied due to incompletion of conservative treatment and lack of joint X-rays. He had previously undergone arthroscopic surgery to his right shoulder.

The patient first reported pain to the left shoulder 5 months ago, and there is no documentation that a physical examination was completed at that time; no X-ray and no differential diagnosis is provided. Later physician visits showed no confirmation of conservative treatment nor an X- ray. The ultrasound (US) report was not provided. 

There is no indication for Magnetic Resonance Imaging (MRI). An MRI can provide additional information in diagnosing and planning treatment. Prior to such there should be a full course of conservative management. An initial X -ray should also be completed to aid in differential diagnosis. 

It is unclear how moving a shoulder or performing shoulder exercises has any effect on an umbilical hernia thus preventing physical therapy. Based upon no X-ray, no ultrasound (US) report and no documented conservative treatment, there would be no indication for the study. 

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 shoulder MRI (magnetic resonance imaging) left- pictures of inside your shoulder, visits/units requested: 1 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Saxenda

The insurer denied coverage for Saxenda

The denial is  overturned

 
This is an adult female diagnosed with Obesity. This request is for Saxenda. As reported; she has been a patient at FORM, a physician led medical weight loss program where patients are with their care team 3 times per months. She has a Body Mass Index (BMI) of 47.1. She has hypertension (HTN). She has tried Weight Watchers and Noom with success and she lost 25 pounds. She is tolerating metformin 1000 milligrams (mg) and then increased to 2000 mg daily. She has a history of gestational diabetes. Her most recent glycated hemoglobin (A1C) is 5.3 % (percent). 

Saxenda is used in the treatment of obesity[1-7]. The standard of care is to use the medication most compatible with the patient's condition and other medications. The standard of care requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. 

The patient has a BMI of 47.4 and participates in lifestyle modifications such as diet and exercise. The request is consistent with generally accepted standards of medical practice. 

Based on the above, the insurer's denial must be overturned. 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 Saxenda is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a female admitted for diagnosis of intractable abdominal pain. The patient presented with a chief complaint of intractable abdominal pain. Vital signs demonstrated temperature 98.3F (degrees Fahrenheit), pulse 67, respiratory rate 18, blood pressure 157/85 and O2 (oxygen) saturation 98% (percent) on room air. Physical exam showed mild distress due to pain with no altered mental status. There was generalized abdominal mild tenderness. Abdominal pain was thought to be secondary to cannabis hyperemesis syndrome versus acute gastroenteritis versus IBS (inflammatory bowel disease) flare. 

The inpatient hospital admission was not medically necessary.
The patient in this case was admitted for abdominal pain but did not have a cause of abdominal pain thought to be life-threatening. There was no unstable vital sign, peritonitis, acute bowel obstruction, mesenteric ischemia, perforation, myocardial infarction or ectopic pregnancy. The symptoms improved with fluid hydration and electrolyte replacement. She did not require any specific intervention for treatment of abdominal pain. She was then recommended to follow up with gastroenterology on an outpatient basis.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: palpitations

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Asked to review the case of an adult male that presented to the hospital complaining of palpitations. Past medical history was significant for a supraventricular tachycardia.  CHADSVASC score (a point-based system used to stratify the risk of stroke in Atrial Fibrillation  patients) was zero.  On arrival to the hospital the patient was hemodynamically stable and tachycardic: Blood Pressure 130/82, Pulse 155. Physical examination was significant only for a rapid pulse.  12 lead electrocardiogram (EKG) demonstrated atrial flutter with rapid ventricular rate (155). The patient was treated with intravenous diltiazem to control heart rate.  He was admitted to the telemetry unit and rhythm reverted to normal sinus overnight. Paroxysmal atrial fibrillation was also noted. Echocardiogram demonstrated a preserved ejection fraction (EF) of 59%(percent) and no valvular abnormalities. The patient was discharged the following day on atrial -ventricular (AV) nodal blocking agents.

This patient presented with symptomatic atrial flutter and fibrillation.  He was effectively treated with AV nodal blocking agents.  Following evaluation and additional testing, the patient reverted to normal sinus rhythm and was released from the hospital.  Bellew et al studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department.  In this study of almost 600 patients, there was no difference in outcome.  American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation is not necessary in patients that achieve rate control. (Reference 2) This patient reverted to normal sinus rhythm several hours after presentation.  In conclusion, admission to the hospital for treatment of paroxysmal atrial fibrillation was not medically necessary.

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal and leg pains
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is an adult who presented to the emergency room (ER) with abdominal and leg pains. On day 2 of the admission, he had a fever of 101 degrees Fahrenheit but subsequently was afebrile. There were no peritoneal signs. There was no leukocytosis. There was elevation of the liver enzymes. A sonogram showed gallstones and a hepatobiliary iminodiacetic acid (HIDA) scan was consistent with cholecystitis but there was no common bile duct (CBD) obstruction. The magnetic resonance cholangiopancreatography (MRCP) suggested the presence of cholangiocarcinoma. An endoscopic retrograde cholangiopancreatography (ERCP) showed a common bile duct (CBD) stricture, and a stent was placed. Cytology brushings were done. The patient was started on intravenous (IV) antibiotics but then switched to oral antibiotics. The impression was that he had cholangiocarcinoma. The leg pains were felt to be a possible paraneoplastic syndrome. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-555 for Gallbladder or Bile Duct Inflammation or Obstruction. Clinical indications for admission include having acute cholecystitis or acute cholangitis with systemic signs of inflammation. In this case, the patient had a stricture in the CBD that was felt to be a cholangiocarcinoma. There was no evidence of acute cholangitis. He also had gallstones but did not have a clinical diagnosis of acute cholecystitis. The patient did not have hemodynamic instability, severe vomiting, severe pain, or dehydration. 

This patient required a workup for a suspected cholangiocarcinoma. There was no evidence of acute cholangitis or severe sepsis. The imaging studies could have been done as an outpatient. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient has a history of fibroids and chronic anemia who presented to the emergency department (ED) complaining of vaginal bleeding of 1 week duration. She reported feeling dizzy and lightheaded. Vital signs were stable. There was no evidence of active bleeding on pelvic examination. Hemoglobin was 6.3. She was transfused with 2 units packed red blood cells (PRBCs) in the ED and was admitted for transfusion and received 2 more units on the floor. Repeat Hemoglobin was 11.8. She was discharged home to follow up with her gynecologist. 

This patient fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 so, transfusion was necessary. 

Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission. The transfusion was started in the ED. The transfusion could have been completed in the ED without the need for admission. Following transfusion, the patient could have been monitored for a few hours in the ED, her complete blood count repeated and then discharged home with a follow up within 24 hours with her primary physician or gynecologist. 

Nothing was done in the hospital that could not be done as an outpatient. Milliman Care Guidelines (MCG) list the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. The patient was stable and did not have any of the above indications for admission. 

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 an inpatient admission is not substantiated.