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

Diagnosis: Asthma.
Treatment: Hospital Admission.
The insurer denied the hospital admission.
The health plan's determination is overturned.

The patient is a male who presented with an asthma exacerbation. He was well until 2 days prior to presentation when he developed a cough. His symptoms worsened, and he vomited twice the day prior to presentation. He then developed difficulty breathing. Home treatments with a nebulizer were not working, so he was brought to the emergency department for care.
In the emergency department he was found to have decreased air movement with wheezing. He received 3 Albuterol/Atrovent nebulized treatments as well as intravenous Decadron and Magnesium Sulfate. A Normal Saline bolus was also given. After treatments, he continued to have decreased air entry and his oxygen saturation dipped to 93 to 94 percent (%) on room air. He was therefore subsequently admitted for further treatment of status asthmaticus. His past history is significant for an asthma admission 1 year ago.
Upon admission he continued to have a prolonged expiratory phase with wheezing. He was continued on intravenous fluids as well as Albuterol every 3 hours and Prelone. He was diagnosed with moderate persistent asthma and started on Symbicort. He continued to have some wheezing during the admission, but he was weaned off supplemental oxygen and was spaced to every 4-hour Albuterol treatments. He was felt to be stable for discharge to home at that time, with follow up as an outpatient.

The health plan, in its determination of medical necessity, has not acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of a hospital admission is medically necessary for this patient. The patient presented with status asthmaticus. He continued to have significant wheezing despite appropriate and aggressive treatment in the emergency department, including bronchodilators, Magnesium Sulfate, and Decadron. He also experienced desaturation down to 93% on room air. He required ongoing care in a hospital setting to receive frequent bronchodilator therapy (initially every 3 hours), supplemental oxygen as needed, and intravenous fluids to maintain his hydration status.
The decision making at the time of admission for this patient was consistent with his age, the presence of significant wheezing and decreased air movement despite appropriate treatment at home and in the emergency department setting, and the need for ongoing intensive therapies in an inpatient setting along with close monitoring for potential deterioration of clinical status.
Hospitalization is indicated for patients with status asthmaticus who required frequent bronchodilator therapy (more often than every 4 hours) as well as other intensive treatments including intravenous fluids, supplemental oxygen as needed, and close monitoring.

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

Diagnosis: Left leg venous disease.

Treatment: Procedure code 36475 (heat treatment of main leg veins).

The insurer denied coverage for procedure code 36475 (heat treatment of main leg veins).

The denial is overturned.

 
This is an adult patient who has been evaluated and treated for left leg venous disease including left common iliac stenting. The patient presented to the Vein Clinic for evaluation and management the patient's left leg swelling and the need for left great saphenous vein (GSV) procedure, CPT 36475.  The insurer has denied coverage for procedure code 36475 (heat treatment of main leg veins). 

Clinic note states patient was examined for Left Leg swelling with no documented edema but possible skin changes.

Procedure note states patient underwent Left Iliac Stenting.

Family Medicine note states patient is morbidly obese. No edema documented of bilateral legs.

Computed tomography (CT) Venogram suggested left May-Thurner Syndrome.

Venous Duplex shows bilateral Sapheno-femoral junction (SFJ) Reflux.

Scrotal Ultrasound shows bilateral hydroceles.

As per this second Letter of Denial it appears that the requirements for limiting symptoms and conservative therapy has been met.

Venous Duplex documents bilateral SFJ: (Saphenofemoral Junction) (near the top of the vein) significant Venous Reflux Disease. Therefore, the CPT 36475 of the left great saphenous vein (GSV) should be approved.      

Medical documentation supports limiting symptoms. Conservative therapy has been tried and failed. The Venous Duplex documents bilateral SFJ: (Saphenofemoral) Junction (near the top of the vein) significant Venous Reflux Disease. Therefore, the CPT 36475 of the left great saphenous vein (GSV) is considered medically necessary for this patient.

Per Scovell, S. Alquire, P. (2018), "Chronic venous disease refers to a wide spectrum of morphologic (i.e., venous dilation) and/or functional abnormalities (e.g., venous reflux) of long duration. Vein-related problems may or may not be symptomatic and include a wide range of clinical signs that vary from minimal superficial venous dilation to chronic skin changes with ulceration. Inadequate muscle pump function, incompetent venous valves (reflux), and venous thrombosis or obstruction are causes of elevated venous pressure (venous hypertension), which initiates a sequence of anatomic, physiologic, and histologic changes leading to vein dilation, skin changes, or skin ulceration. The factors that determine whether a given patient will progress from mild to more severe disease are largely unknown." 

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 procedure code 36475 (heat treatment of main leg veins) is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD.
Treatment: LINX Procedure.
The insurer denied the LINX Procedure.
The determination is upheld.

This is a male patient who has medically refractory gastroesophageal reflux disease (GERD). An esophagogastroduodenoscopy (EGD) showed Barrett's esophagus and a small hiatal hernia. Under the EGD section, it says yes for Barrett's esophagus. Sometimes on EGD findings they do not see Barrett's, but the biopsy shows Barrett's. I do not see the pathology report in the documents, but the provider wrote yes for Barrett's. An upper gastrointestinal (UGI) study showed gastroesophageal reflux disease (GERD) and a hiatal hernia. The patient had a DeMeester score of 36.8. Manometry was normal. At issue is whether the LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No. The LINX procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has medically refractory gastroesophageal reflux disease (GERD) but has Barrett's esophagus. LINX has not been proven safe in patients with Barrett's esophagus As per the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES): The LINX device has not been evaluated in patients with a hiatal hernia larger than 3-centimeters (cm). Use of LINX device in patients with a hiatal hernia larger than 3-cm should be considered on the basis of each patient's medical history and severity of symptoms.
The safety and effectiveness of the LINX device has not been evaluated in patients with Barrett's esophagus or Grade C or D (LA classification) esophagitis. The safety and effectiveness of the LINX device has not been evaluated in patients with major motility disorders.
The safety and effectiveness of the LINX Reflux Management System has not been established for the following conditions:
- Scleroderma.
- Suspected or confirmed esophageal or gastric cancer.
- Prior esophageal or gastric surgery or endoscopic intervention.
- Distal esophageal motility less than 35-millimeters of mercury (mmHg) peristaltic amplitude on wet swallows or less than 70 percent (%) (propulsive) peristaltic sequences or a known motility disorder (such as Achalasia, Nutcracker Esophagus, and Diffuse Esophageal Spasm or Hypertensive lower esophageal sphincter (LES)).
- Symptoms of dysphagia more than once per week within the last 3 months.
- Esophageal stricture or gross esophageal anatomic abnormalities (Schatzki's ring, obstructive lesions, etc.).
- Esophageal or gastric varices.
- Morbid obesity (body mass index (BMI) greater than35.
- Age less than 21
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Treatment: LINX Procedure
The insurer denied the LINX Procedure.
The determination is overturned.

This is a male patient with a body mass index (BMI) of 27 kilograms per square meter (kg/m2) who has a history of gastroesophageal reflux disease (GERD) and osteopenia. The patient has found relief with medication proton pump inhibitor (PPI); however, he has chronic osteopenia related to PPI intake (more than 20 years). A 24 hour potential hydrogen (pH) study revealed an elevated DeMeester score of 36.8 consistent with severe GERD. Manometry was normal. A small hiatal hernia (HH) was found on esophagogastroduodenoscopy (EGD).  Barrett's esophagus may have been questioned grossly, however, the pathology/histology of the esophagus documents no presence of Barrett's esophagus. Barrett's esophagus would be confirmed histologically; therefore, this patient does not have evidence of Barrett's esophagus. The patient does not have prior foregut history. At issue is whether the LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. This patient has GERD which responds to medication use; however, he has developed the complication of osteopenia secondary to long-term PPI use for many years. Without medication, the patient is very symptomatic. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and the LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The patient is unable to continue PPI medication secondary to complications related to long-term use. LINX is appropriate for treatment of long-standing GERD. LINX is considered a standard surgical treatment for GERD within the medical community and is recommended in updated published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid to long-term outcomes based on published findings. There are only a few exclusions to the treatment of which the patient has none- he is at least 18 years of age and does not have a history of prior gastric or bariatric surgery, BMI greater than 35 kg/m2, evidence of Barrett's esophagus with dysplasia or large hiatal hernia (3 centimeters (cm)).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pre-term newborn.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.
 

Newborn infant born at 34 weeks gestation, weighing 2550 grams, via cesarean section (in labor). Maternal history included hypothyroidism, gestational diabetes, and pending for Group B streptococcus and intrapartum treatment with Penicillin G. Rupture of Membranes was 14 hours. There was no maternal fever. Apgars were 9 and 9 at one and five minutes, respectively. The infant was admitted to the neonatal intensive care unit (NICU) with a normal physical examination. He was placed on ampicillin and gentamicin for possible sepsis after a blood culture was obtained.  A white blood cell (WBC) count was 7.5 (normal). Care included multiple point of care (POC) glucoses (all normal), initiation of feedings of early breast milk or Similac Advance. Hepatitis B vaccine was administered. The infant was placed on continuous cardiac monitoring, apnea monitoring, and pulse oximetry. Subsequently, the infant did well. There was no apnea or bradycardia documented. A total serum bilirubin (TSB) was 7.1 at 32 hours and treatment was not indicated. Antibiotics were discontinued with a negative blood culture. 

The insurer acknowledged that the patient was "born early" but denied admission to the NICU on the basis of severity of problems stating: "To approve this service, the following criteria must be met: Your child needed to have a severe medical condition that required inpatient treatment and management in the neonatal intensive care unit.  Furthermore, "these criteria are not met because InterQual 2021 Acute Pediatric Nursery, NICU (Neonatal intensive care unit) Level of Care: Levels 2,3 and 4 criteria were not met."

However: according to InterQual Nursery, Special Care Level II, admission is indicated for anti-infective treatment in an asymptomatic patient. Also, according to Milliman Care Guidelines (MCG): ORG: P-358 (ISC): Prematurity Greater Than 1000 Grams and Greater Than 28 weeks: Admission is indicated for premature delivery and according to Level of Care (LOC):LOC-005 ISC GRG, Neonatal Facility, Level II: A Level II Special Care Unit is indicated for neonate requiring care for 1 or more of the following: Moderate-severity condition (e.g., suspected sepsis, transitional hypoglycemia), as indicated by ALL of the following: - Expected to resolve rapidly - or Not expected to require urgent pediatric medical or surgical subspecialty care.

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 inpatient admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: Chronic low back pain.

Treatment: current procedural terminology (CPT) code 64628, intraosseous basivertebral nerve ablation.

The insurer denied coverage for current procedural terminology (CPT) code 64628, intraosseous basivertebral nerve ablation.

The denial is upheld.

This patient has chronic low back pain. Her trial medications for pain have included Gabapentin, Oxycodone,Voltaren Gel, Celebrex and Tylenol. Her magnetic resonance imaging (MRI) shows lumbar (L)5- sacral (S)1 disc herniation with the disc impinging on the Left S1 nerve root and L4-L5 disc herniation abutting the L5 nerve roots bilaterally. She had an Epidural Steroid injection which provided 2 days of pain relief. The request is for the radiofrequency ablation (RFA) of the basivertebral nerves.

Conger et al (and others) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the basivertebral nerve (BVN). Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Urits et al also commented on the need for more research on this promising technique: "reproducible large randomized controlled trials (RCTs) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF (radiofrequency) ablation in the management of chronic low back pain (cLBP) and improve the quality of life of cLBP patients in the near future."

This procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of current procedural terminology (CPT) code 64628, intraosseous basivertebral nerve ablation 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: Medical necessity
Decision: Upheld

Diagnosis: Back pain, arthritis. 
Treatment: Home health care. 

The insurer denied Personal Care Aide Services (PCA) (Consumer Direct, 1 Client): 72.5 Hours per week. 

The health plan's determination is upheld. 

The patient is a female with history of spinal stenosis resulting in chronic back pain, severe arthritis, neuropathy, macular edema of both eyes, diabetic retinopathy, sleep apnea, congestive heart failure (CHF), and hyperactive bladder. She had recent falls and had an episode of urinary tract infection (UTI) resulting in hospitalization. 

No, the requested health service/treatment of Personal Care Aide Services (Consumer Direct, 1 Client): 72.5 Hours per Week are not medically necessary for this patient. 
Based on the records provided, the requested increase in PCA services is not indicated. The patient has PCA services available during the day time and her claim that having bedside commode will not be hygienic could be handled by appropriate care during the daytime. Having a bedside commode is not uncommon for patients with limited mobility and could be used while maintaining the appropriate care. 

PCA services typically fall under personal care, domestic services, paramedical services and paramedical services. Personal services included ambulation, bathing, dressing grooming, bathing, feeding etc., other services include cleaning, bedding, laundry, dusting etc., other related services also include preparation of food, meal cleaning, menu planning, transportation, shopping, money management, etc. Paramedical services include administration of medications, bowel regimen, inserting a medical device into body orifices etc. 

Based on the records provided in this case, the patient only needs assistance for a very few of these services. Her needs can be met by the hours allotted by the health plan. A Bedside commode at night is very appropriate intervention and should be utilized.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Issues
Treatment: Full braces and monthly brace adjustment visits
The insurer denied full braces and monthly brace adjustment visits.
The health plan's determination is upheld.

The patient is a female with a Class I occlusion with 2 millimeter (mm) overbite and 2 mm overjet. She has minor maxillary and mandibular crowding. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion but her insurance company rejected the claim on the basis that treatment is not medically necessary.  

The requested health service/treatment of full braces and monthly brace adjustment visits is not medically necessary for this patient. There is no medical reason to correct her malocclusion with braces. While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. 

Her overbite is appropriate and there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) to this patient.

There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If her teeth were aligned, it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.

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

Diagnosis: Febrile Illness, Rhabdomyolysis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male with a recent history of Coronavirus (COVID-19) infection who presented to the emergency department (ED) with a complaint of fever and malaise. His symptoms began 3 days prior; his maximum temperature was 104 degrees Fahrenheit (F). He was evaluated at urgent care the day prior with negative testing for strep throat, mononucleosis, flu, and COVID-19. He returned to urgent care the day of admission and had a normal chest x-ray and electrocardiogram (EKG). He was started on Augmentin and received 1 dose. The review of symptoms (ROS) was positive for right-sided chest pain with deep breaths, lightheadedness, neck pain, and lymphadenopathy. He was negative for headache, sore throat, runny nose, shortness of breath (SOB), gastrointestinal (GI) illness, dysuria, or discharge.

His ED vital signs were temperature 102.4 F, heart rate (HR) 120, respiratory rate (RR) 18, blood pressure (BP) 115/76 and his peripheral capillary oxygen saturation (SpO2) was 96 percent (%) on room air. The examination was unremarkable. The repeat chest x-ray (CXR) and EKG were normal. The soft tissue neck x-ray was normal. His white blood cell (WBC) count was 2.9, his hemoglobin (Hgb) was 12.8, his platelets (Plt) were 115, his electrolytes were normal, his creatine phosphokinase (CPK) was 1136 and his lactate was 0.6. The respiratory panel was unrevealing. The patient was given intravenous fluids (IVF) and intravenous (IV) Acetaminophen and he was admitted to the hospital for treatment of rhabdomyolysis.

The health plan, in its determination of medical necessity, acted reasonably and with sound medical judgment.

The requested inpatient hospitalization was not considered medically necessary for this patient. The patient presented with fevers and malaise. He had been seen twice in urgent care with normal workups and was started on antibiotics. He presented to the ED and was found to have creatine kinase (CK) greater than (>) 1000, meeting the definition for rhabdomyolysis. However, the patient did not show myoglobinuria or acute renal injury. He did not have vomiting or the inability to take oral liquids. His electrolytes were normal. Therefore, IVF hydration and stabilization in the ED or an alternate level of care with close outpatient follow-up would have been appropriate.

The health plan's determination of medical necessity is upheld in whole.