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

Diagnosis: Inferior Ischemia.

Treatment: Catheterization and ventriculography (code 93458).

The insurer denied coverage for catheterization and ventriculography (code 93458).

The denial is upheld.

The patient presented with a history of hypertension, morbid obesity and a positive stress test who underwent cardiac catheterization. Medical records document no reports of symptomatic ischemic heart disease.  Physical examination is without abnormalities. The patient's medications include chlorthalidone and ramipril. The patient underwent an exercise electrocardiogram (ECG) testing and achieved 5 METS (metabolic equivalents - unit of measurement).  Subsequently, regadenoson myocardial perfusion study was performed and demonstrated a small area of inferior wall ischemia and left ventricular (LV) ejection fraction of 53% (percent). Twelve-lead ECG revealed normal sinus rhythm with normal intervals and no evidence of ischemia or infarction.

Myocardial perfusion testing should be performed on patients with intermediate pretest probability of coronary artery disease. (1)  

This patient had no symptoms of chest pain or unstable angina. His pretest probability of coronary artery disease is low. (2) 

Moreover, findings on myocardial perfusion study are consistent with a low risk of significant ischemic heart disease.  The patient has no symptoms of chest pain or ischemic heart disease and is not treated with beta blocker or antianginal agents.  

American Heart Association/ American College of Cardiology (AHA/ACC) guidelines recommend cardiac catheterization for patients with symptomatic ischemic heart disease that do not respond to medical therapy. (2,3) 

In fact, guidelines note that cardiac catheterization is of no benefit for patients with a left ventricular ejection fraction (LVEF) of >50% and a low-risk criteria on non-invasive testing (Class III indication) (Reference 2). 

In conclusion, heart catheterization and ventriculography (code 93458) were not medically necessary.

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

The insurer's denial of coverage for heart catheterization and ventriculography (code 93458) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient admission. 

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

This female patient has a history of anemia. 

In this case, the patient does not meet the Milliman Care Guidelines (MCG) guideline for admission. The patient presented to the Emergency Department in no acute distress as evidenced by a normal appearance with no focal deficit, alert, and oriented to person, place, and time. Upon admission, she denied any syncope, lightheadedness, chest pain, palpitations, shortness of breath, or abdominal pain. Her vital signs were unremarkable with a blood pressure (BP) of 129/87, normal pulse rate of 86, and a normal oxygen saturation of 100%. The electrocardiogram (ECG) revealed normal sinus rhythm and the diagnostic tests revealed no acute abnormalities. Although the patient had critically low hemoglobin levels, the scenario could have been handled in an outpatient setting in the emergency department, rapid treatment site, or urgent care center. The inpatient level of care was not appropriate per nationally recognized screening criteria.  Therefore, based on the documentation reviewed and peer-reviewed criteria and literature, the request for inpatient stay from is considered not medically necessary. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD).
Treatment:  Lansoprazole ODT (orally dissolving tablet), Pre-service.
The insurer denied the  Lansoprazole ODT (orally dissolving tablet), Pre-service.
The denial is overturned.

This is a female patient with cerebral palsy, dysphagia, and gastrostomy in place who requires to feed and medication administration via gastrostomy tube.  The request is for lansoprazole ODT (orally dissolving tablet).

The prior denial reason was due to the health plan's preferred alternatives being lansoprazole delayed release, omeprazole delayed release, pantoprazole delayed release, and Dexilant.  The reason the physician is appealing the determination is that the patient has had a previous response to the requested agent.  In addition, the patient cannot swallow pills.

Yes, the health plan should cover the proposed treatment.
Given this patient's inability to swallow, use of lansoprazole delayed release, omeprazole delayed release, pantoprazole delayed release, and Dexilant would not be indicated.

Literature does not suggest that there is any benefit of one proton pump inhibitor (PPI) over another. According to the American College of Gastroenterology (ACG) Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease (GERD), there are no major differences in the efficacy between the different PPIs (proton pump inhibitor) (Strong recommendation, high level of evidence).

The agents would have similar side effects.  The documentation does not support trial / failure of the alternatives.  However, lansoprazole ODT (orally dissolving tablet) does not have to be swallowed and dissolves within the mouth; this would be preferred due to the patient's dysphagia and presence of a gastrostomy tube.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malnutrition. 
Treatment: Ensure. 

The insurer denied coverage for Ensure. 

The denial is upheld. 

This adult male patient is homeless and does not have access to a kitchen or cooking facilities. He has bipolar disorder. He also has an opioid use disorder. A psychiatric evaluation advised that supportive housing, outpatient psychiatric care, and opioid treatment be provided. 

UpToDate discusses malnutrition in "Geriatric nutrition: Nutritional issues in older adults." The article states that nutritional supplementation resulted in modest improvement in percentage weight gain. The recommendation is that if food intake is inadequate, a liquid dietary supplement should be considered. 

There is a role in giving dietary supplements to patients who are malnourished. However, in this case, records show that the body mass index (BMI) is 18.47. A healthy BMI is 18.5 to 24.9. Based on this result there is no indication that he is significantly malnourished. The patient has psychological reasons as to why he cannot take care of himself. However, there is no medical documentation provided why the patient cannot eat a regular food diet. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. Ensure has not been documented to be medically necessary. 

The insurer's denial of coverage for Ensure is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment:  D8080 Braces and D8670 Monthly Visit x 12.
The insurer denied the D8080 Braces and D8670 Monthly Visit x 12.
The denial is overturned.

The patient is a male with Skeletal Class I malocclusion. He has impacted lower permanent canines, severe lower crowding, deep bite and protruding upper and lower incisors.

Yes, the braces and monthly visits are medically necessary.
The patient has impacted lower permanent canines, teeth #s 22 and 27. When there are impacted permanent anterior teeth where extractions are not indicated, this is an automatic qualifier according to the handicapping index scale. Therefore, the braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis.
Treatment: Reclast intravenous (IV) Infusion.
The insurer denied the Reclast intravenous (IV) Infusion.
The denial is overturned.

The patient is a male with osteoporosis. The request for Reclast is under review. The prior request was denied as approval requires that the patient has severe intolerance, ineffective response, or contraindication to oral bisphosphonate therapy or the patient has had a prior fragility fracture or is especially high fracture risk. The attending physician is appealing this determination because this patient has a T-score of -2.9. He fractured his left tibia while roller skating. He stated it was not a big fall. He completed a two-year course of Forteo. He tried Fosamax three years ago, and again three months ago, and experienced severe gastrointestinal upset. He also tried and was intolerant to Actonel, which resulted in emergency room visit due to severe gastrointestinal upset.

Yes, the requested Reclast is medically necessary.
This patient has osteoporosis and has completed a two year course of Forteo. He has tried and had severe intolerance to both Fosamax and Actonel. Without Reclast, this patient is at risk of losing bone density that he gained with the Forteo treatment he received, which would put him at high risk for a fragility fracture. Therefore, yes, the requested Reclast is medically necessary.

This patient had a severe intolerance to oral bisphosphonates. The requested Reclast is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hair Loss. 
Treatment: Xeljanz oral solution (tofacitinib). 

The insurer is denied coverage for Xeljanz oral solution (tofacitinib). 

The denial is upheld. 

This female patient has a history of alopecia universalis. 

The patient has not failed or shown to have a contraindication to numerous therapies known to possibly improve alopecia universalis, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), calcipotriene, and anthralin. (1- 11) Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata and related conditions, further studies are needed to demonstrate the long-term efficacy and safety of Xeljanz. It is noted that the Food and Drug Administration (FDA) released a statement in early 2019 finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg bid. (1) Based on the submitted documentation, Xeljanz is not medically necessary for the patient's condition, alopecia universalis. 

The standard of care for treatment of alopecia universalis would necessitate an attempt to use the above-mentioned options for the treatment of alopecia universalis. The patient has not failed or shown to have a contraindication to numerous therapies known to possible improve her condition, including light therapy, squaric acid, DPCP, and anthralin. (9- 11) 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the Xeljanz oral solution (tofacitinib) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of stroke with residual hemiplegia, cognitive decline, generalized anxiety disorder, depression and chronic low back pain
Treatment: Increase in Personal Care Assistance Services From 70 To 168 Hours Per Week
The insurer denied the increase in personal care assistance services from 70 to 168 hours per week.
The denial is overturned. 

The patient is a female with a history of stroke with residual hemiplegia, cognitive decline, generalized anxiety disorder, depression and chronic low back pain. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 168 hours/week personal care assistance (PCA) services to offer increased ADL support.

Yes, the increase in PCA services from 70 to 168 hours per week is medically necessary.

Although an assessment of the patient's functionality and ability to perform ADLs was completed and noted that the currently approved plan of 70 hours/week PCA services is sufficient to meet the patient's current needs, the patient's primary care physician relates that this reduced schedule leaves her home alone, completely unassisted for numerous hours/day. This is problematic as she requires assistance with her activities of daily living including bathing, dressing, grooming, skin care, toileting, transferring and repositioning, feeding, meal preparation and prompting to take her medications. Furthermore, she is only able to ambulate short distances with the use of a walker and is at high risk for falls.

Hence, provision of 168 hours/week PCA services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 168 hours/week PCA services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: major neurocognitive disorder

Treatment: consumer directed personal assistance services (CDPAS) of 24 hours per day, split shift (12 hours x 2 shifts), 7 days per week

The insurer is denied coverage for consumer directed personal assistance services (CDPAS) of 24 hours per day, split shift (12 hours x 2 shifts), 7 days per week

The denial is upheld. 

This female patient has a history of Alzheimer's dementia with behavioral disturbances, major depressive disorder, panic disorder, major neurocognitive disorder, bilateral hearing loss, chronic insomnia, astigmatism, cataracts, vitamin B 12 deficiency, vitamin D deficiency, orthopnea, multiple falls, essential hypertension, diabetes mellitus, hyperlipidemia, primary osteoarthritis, mild persistent asthma, functional dyspepsia, chronic constipation, chronic migraines and osteopenia.  

She is totally dependent for ordinary housework.  The patient needs maximum assistance with meal preparation, managing finances, managing medications, phone use, managing stairs, shopping and transportation. She needs extensive assistance with bathing, personal hygiene, dressing her upper and lower body, walking, locomotion, toilet transfer and toilet use. The patient uses an assistive device for locomotion. It was noted that the patient has frequent falls, and there was one fall reported in the last 30 days. It was also noted that the patient wanders. She needs supervision with bed mobility and limited assistance with eating.
The patient is infrequently bladder incontinent but is bowel continent.
The patient has infrequent urinary incontinence. There is no skin breakdown. She can make her needs known. There is no documentation supporting the need for nightime turning and positioning . The plan has offered to do a sleep study of the patient to determine if in fact an aide would need to be constantly awake in order to provide covered services; these would need to be beyond supervision only. She would then qualify for split-shift. This was refused by the family.  

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the consumer directed personal assistance services (CDPAS) of 24 hours per day, split shift (12 hours x 2 shifts), 7 days per week is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female with a history of hypertension, allergic reaction triggers unknown, who was hospitalized for acute symptoms of shortness of breath and angioedema.  The patient had presented to the emergency room and was treated with epinephrine and steroids.  The patient was evaluated by specialties such as Pulmonary Medicine and Allergy Service.  The testing performed during the hospitalization was unremarkable.

No, the proposed treatment of inpatient hospitalization does not meet the criteria for medical necessity.
Upon review of medical records, including emergency room records, laboratory testing records, hospitalization treatment and testing records, it was not evident that the patient was having hemodynamic instability at the time of admission for inpatient care.  Upon presentation to the emergency room, the patient was found to be afebrile, with stable blood pressure and elevated heart rate.  Her physical examination had not revealed significant pulmonary function issues such as wheezing, and her ear nose and throat (ENT) examination did not reveal obstruction in the oropharynx that showed airway compromise.  Her laboratory testing records show elevated white blood cell count, which was likely due to prior oral steroid use.  She also did not present with altered mental status, and was noted to be alert, awake and oriented.  She continued to be monitored for symptoms of worsening angioedema/breathing problems, which could be performed at a lower level of care, such as observational stay, rather than inpatient care.  Furthermore, the testing such as evaluation for angioedema, radiologic imaging studies can also be performed at the observational care level.  In summary, there were insufficient findings on her physical examination, or vital signs to suggest that she was hemodynamically instable at the time of inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: percutaneous revascularization

Treatment: inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization

The denial is upheld. 

This male patient has a history of coronary artery disease (CAD), systolic heart failure, hyperlipidemia, pancreatic colonic lesions, sigmoidectomy, occluded right and left superficial femoral arteries, and hypertension (HTN).

This patient presented for elective percutaneous revascularization. He underwent an uncomplicated procedure, and a stent was placed in the mid right coronary artery. He was subsequently discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (1-4) Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. (4) In conclusion inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospitalization is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spondylosis without myelopathy or radiculopathy and low back pain.

Treatment: Intracept procedure for intraosseous ablation of basivertebral nerve, codes 22899 (unlisted procedure, spine), C9752 (destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance [e.g., fluoroscopy], lumbar/sacrum) and C9753 (destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance [e.g., fluoroscopy], lumbar/sacrum)

The insurer denied coverage for Intracept procedure for intraosseous ablation of basivertebral nerve, codes 22899 (unlisted procedure, spine), C9752 (destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance [e.g., fluoroscopy], lumbar/sacrum) and C9753 (destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance [e.g., fluoroscopy], lumbar/sacrum).

The denial is upheld. 

This male patient has a history of spondylosis without myelopathy or radiculopathy and low back pain.

As summarized by Up to Date, "We suggest not using radiofrequency denervation for the management of chronic low back pain. The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term; however, there does not appear to be clear long-term benefit [59-68]. When added to a treatment regimen that includes a regular exercise program and psychologic support, radiofrequency denervation provides little additional benefit."

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

The carrier's denial of coverage for the Intracept procedure for intraosseous ablation of basivertebral nerve, codes 22899 (unlisted procedure, spine), C9752 (destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance [e.g., fluoroscopy], lumbar/sacrum) and C9753 (destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance [e.g., fluoroscopy], lumbar/sacrum) is upheld. The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Seizures

Treatment Briviact 25 milligram (mg) tablet

The insurer denied coverage for Briviact 25 milligram (mg) tablet

The denial is upheld

The patient has a history of focal motor seizures. The patient has been treated with aptiom and Keppra. She has also tried clonazepam with adverse effects of unsteadiness, rash and increased seizure activity. The provider prescribed Briviact 25 milligram (mg) tablets and that was denied.

The formulary drugs are not likely to cause an adverse reaction. Per the provided clinical documentation the patient does not have contraindication, intolerance, or failure to all the available formulary drugs.      

The formulary drugs have not been ineffective based on the claimant's clinical history. The Patient has tried and failed only two of the alternative medications for seizure activity. The claimant has tried and failed Aptiom and Keppra.    Note that Keppra- levetiracetam-which the patient has tried is similar to Briviact- brivaracetam. As per Up to Date " Like levetiracetam, brivaracetam binds to the synaptic vesicle protein synaptic vesicle glycoprotein 2A (SV2A), which has been linked in animal models to epilepsy."  Also "The comparative tolerability between brivaracetam and levetiracetam is not yet known. A systematic review identified five studies that included a subset of people with epilepsy who switched from levetiracetam to brivaracetam, which was associated with improvement in behavioral adverse events in 33 to 83 percent of patients [15]. Still, a retrospective postmarketing study included in the systematic review also found that patients with a history of behavioral adverse effects on levetiracetam were at increased risk for behavioral adverse effects from brivaracetam (odds ratio 3.5) [16].."  This does not support the use of Briviact in this patient.

There is insufficient peer review literature to support the requested drugs over the available formulary alternatives. Briviact 25 milligram (mg) is not supported to be more effective than the other formulary medications which are reasonable options for this patient's indication. Therefore, the request for Briviact is not likely to be more effective that the formulary options. 

Sarma, A. K., et al, "In the last years, the United States (US) Food and Drug Administration has approved 15 new antiepileptic drugs (AEDs), with many more currently in development. Other advances have been achieved in terms of diagnostic modalities like electroencephalography technology, treatment devices like vagal nerve and deep-brain stimulators, novel alternate routes of drug administration, and improvement in surgical techniques."

The insurer's denial of Formulary Exception for Briviact 25 milligram (mg) tablet is upheld.