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

Diagnosis: Chronic Knee Pain. 
Treatment: Pain Injection (64454 x 1). 
The insurer denied the Pain Injection (64454 x 1), Pre-service. 
The denial is overturned. 

The member is a female with history of chronic bilateral knee pain due to severe Bilateral Knee osteoarthritis that has been ongoing for approximately more than 12 months with the pain affecting her functionality, especially ambulation. 
She has tried and failed Physical Therapy, Tylenol, NSAIDs, intra-articular knee steroid injections, etc. 

The request is for Right knee Genicular Nerve Block. 

Yes, the requested Genicular Nerve Block (GNB) is medically necessary based on the current general standard of care bas stated below: 
1) Is required to treat the diagnosis of Knee pain; 
2) It was provided in accordance with generally accepted standards of medical practice; 
3) it was the most clinically appropriate level of service that can be provided in this instance in terms of type, frequency, extent, site and duration; 
4) It was not primarily for the convenience of a member, Physician or other healthcare Provider; 
5) It was rendered in the least costly setting that is appropriate for the delivery of the procedure. 

In this instance, the requested Genicular Nerve Block is therefore medically necessary as she has severe knee osteoarthritis, failed conservative measures and she is not a candidate for knee surgery. 

In prospective randomized study, Guler et al. stated, "GNB is beneficial in reducing pain and increasing functional and physical capacity, with greater retention of effects on the physical capacity seen at 12 weeks." 

In a randomized clinical trial, Elsaman et al concluded, "GNB has been approved for the treatment of pain in knee osteoarthritis. GNB in this study was able to control active knee arthritis and this effect persisted longer than intra-articular steroid injection." 

The requested Genicular Nerve Block is not experimental/investigational as this is national standard practice for the treatment of severe chronic knee pain in a patient who has failed extensive conservative measures and who is not a surgical candidate and it has been demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating Knee pain. It is therefore medically necessary as against what the health plan stated. 

No, the health plan did not act reasonably in this instance and its decision has no sound medical judgment and not in the best interest of the patient because she has evidence of severe osteoarthritis for which she has tried and failed conservative measures as stated in the clinical summary and this is the less invasive next step in the management of her knee pain. 

MRI (magnetic resonance imaging) of the RIGHT knee showed severe tricompartmental osteoarthritis with mucoid degeneration of the cruciate ligaments along with extensive tear of the menisci.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Recurrent venous thromboembolism. 
Treatment: Eliquis.
The insurer denied the Eliquis. 
The determination is upheld. 

The patient has a history of recurrent venous thromboembolism. The patient is currently on apixaban and is tolerating it well but it is not a formulary option. She has not failed other anticoagulants. Rivaroxaban (Xarelto) is a formulary option. Apixaban (Eliquis) is under review. 

Neither Xarelto nor Warfarin have been demonstrated to be inferior to Eliquis. The included documentation does not indicate that this patient is intolerant of either of the formulary alternatives nor that the patient failed them; similarly, there is a paucity of documentation indicating that this patient has a contraindication to the formulary alternatives. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus, given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Testicular hypofunction. 
Treatment: Testosterone gel. 

The insurer denied coverage for testosterone gel.  The denial is overturned. 

This is a male with past medical history of hypertension, diabetes, hyperlipidemia, renal stones, testicular hypofunction. Patient had a telemedicine visit with the Urologist's office for follow up of erectile dysfunction. Patient reported a history of erectile dysfunction. For low serum TST (testosterone), he was initially started on Testim and then switched to Androderm. The patient reacted poorly to the topical adhesives in the androderm patches. He saw a dermatologist, and this was treated with a topical cream. The treating practitioner recommended topical TST replacement therapy to treat the testicular hypofunction. The insurer has denied coverage for TST gel. The insurer stated they would only cover the TST gel when the treating provider indicates that the patient cannot be switched to a preferred provider. Formulary alternatives are: TST solution, Androderm. The requirement is trial and failure of all formulary alternatives, but not more than 3. The appeal on patient's behalf is noted, read in detail. Patient notes he tried TST solution (cypinate) previously without benefit. He has also tried and failed to achieve therapeutic success with testim, Androderm. This patient has tried/failed on 3 formulary alternatives, (cypinate-TST. Testim, Androderm) and should be allowed to see if he can receive topical TST replacement (androgel) for success treatment of his hypogonadism. 

The formulary drugs are not more likely to cause the patient an adverse reaction. 

The formulary drugs have been ineffective based on the patient's clinical history. 

The requested drug may be more effective than the formulary drugs-that will only be known once patient starts to receive treatment with it. TST-gel should be granted a Formulary Exception for this case. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Formulary Exception for testosterone gel is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lack of coordination.
Treatment: Occupational Therapy (OT).
The insurer denied occupational therapy. 
The health plan's determination is upheld. 

The patient is a male who has a diagnosis of lack of coordination. The Clinical records available are the initial evaluation and plan of care. The initial evaluation documents standardized instruments of Hawaii Early Learning Profile 2nd ed. (HELP-2) with decreased attention and minimal deficit in fine motor skills. Progress notes are also included.

The requested Occupational Therapy Services are not medically necessary for this patient. The patient's therapy progress notes documentation do not support medical necessity for standards of practice for occupational therapy. OT is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition AND all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice.

The goals listed in the progress note documented as having a start date of a year ago. OT conducted recently is therefore working on goals that are over 9 months old. Since the patient has not achieved these goals in that period of time, there is no medical justification for continuing therapy that has not produced substantive improvement in function or developmental milestones.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic breast cancer
Treatment:  PET Scan (procedure code 78815) with Computed Tomography (CT)
The insurer denied the  PET Scan (procedure code 78815) with Computed Tomography (CT)
The denial is upheld

The patient in this case was diagnosed with metastatic breast cancer.  She had an iliac bone biopsy done at that time which confirmed the diagnosis of metastatic breast cancer.  She was started on treatment with THP (Docetaxel, Trastuzumab and Pertuzumabat) at that time.  A PET (positron emission tomography)/ CT (Computed tomography) was done to monitor her status while on treatment.

No, the proposed treatment is not medically necessary.
The patient in this case had a positron emission tomography/computed tomography done to monitor treatment response. She has metastatic breast cancer. Positron
emission tomography/computed tomography is not a standard test for this purpose. There is no conclusive evidence that positron emission tomography/computed tomography improves health outcomes when used for treatment monitoring in patients with metastatic breast cancer compared with conventional imaging. There is no documentation showing that this patient had conventional imaging done with equivocal results. Given these considerations the positron emission tomography/ computed tomography done in this case was not medically necessary.
Therefore, the health plan acted reasonably and with sound medical judgement.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with past medical history significant for hypertension, diabetes mellitus, and chronic obstructive pulmonary disease who presented to the emergency department (ED) with complaints of worsening left foot swelling.

Vitals on presentation included a temperature of 99.2 Fahrenheit, blood pressure 142/90, heart rate 106, respiratory rate 20, oxygen saturations 94% (percent) on room air. Laboratory results included white blood cell (WBC) count of 10.2, hemoglobin 14.2, hematocrit 44.1, and creatinine 0.84.

The patient was started empirically on intravenous antibiotics (Unasyn) for left foot cellulitis. X-ray of the foot showed diffuse soft tissue swelling consistent with given history of cellulitis. There was no evidence of osteomyelitis. The patient remained afebrile and hemodynamically stable. He was discharged to continue oral antibiotics as an outpatient.    

According to documentation, the patient presented to the ED with left foot infection. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. The patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, the patient did not fulfill criteria for acute hospitalization.

The health 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: Abdominal pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with a past medical history of hypertension, who presented for abdominal pain, chills, and urinary urgency. Review of system was negative for additional clinical symptoms.
The patient was afebrile (Temperature of 36.8). She was described as resting in bed and in no acute distress. Her blood pressure was 126/85, pulse rate of 98, respiratory rate of 16, and oxygen saturation of 100% on room air. Physical examination was remarkable for positive for right lower quadrant tenderness to palpation.

The inpatient hospital admission was medically necessary.
The patient was admitted for severe abdominal pain due to a large pelvic abscess versus a mass. The patient required the inpatient level of care for severe pain that required surgical operation and intervention. Pain relief was obtained after removal and drainage of the abscess. Procedural intervention necessitated inpatient level of care. Additionally, the patient has a comorbid condition of a pelvic mass with a prior diagnosis of leiomyosarcoma which increased the risk of complications such as infection and bleeding.
The percutaneous treatment of pelvic abscesses has traditionally involved the placement of drainage catheters via a transgluteal, transrectal, or transvaginal route. These procedures are painful and prolonged. Intensive medical management including the use of broad-spectrum antibiotics, posterior colpotomy, and major surgery involving a hysterectomy and bilateral salpingo-oophorectomy, all have their place in the management of this condition. An Inpatient level of care is necessary for broad spectrum antibiotics, procedural intervention and monitoring for complications after the procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Radiology Services (including Ultrasound) 
The insurer denied Single photon emission computed tomography (SPECT/CT). 
The denial is overturned. 

This case involves a male patient with a history of aortic regurgitation status post bioprosthetic aortic valve replacement (AVR), cardiomyopathy with left ventricular hypertrophy (LVH) present on echocardiogram, hypertension (HTN), hyperlipidemia (HL), and prior subarachnoid hemorrhage treated with burr holes. Due to the presence of significant LVH on echocardiogram imaging and low normal electrocardiogram (ECG) voltage and in the absence of significant hypertension the patient's treating physician has ordered a single-photon emission computed tomography (SPECT)/computed tomography (CT) current procedural terminology (CPT) 78830 to further evaluate for transthyretin (ATTR) cardiac amyloidosis. There is no clinical concern for coronary disease and ischemia given normal coronary angiogram results prior to AVR and recent normal stress echocardiogram. The patient has been ruled out for light chain (AL) disease with normal serum free light chain testing. The patient's health plan has denied coverage for SPECT/CT CPT 78830 on the grounds the test is not medically necessary.
At issue is the medical necessity of SPECT/CT.

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

The requested health service/treatment of SPECT/CT is medically necessary for this patient.

Based on the patient's past medical history of LVH on echocardiogram imaging, low normal ECG voltage in the absence of significant hypertension, SPECT/CT CPT is medically necessary and appropriate for this patient. The patient's prior medical history and testing results have raised the suspicion for possible cardiac ATTR amyloidosis. Per peer reviewed published medical literature on the diagnostic accuracy of nuclear medicine, SPECT/CT imaging when AL disease has been excluded is medically appropriate and necessary in this case for further evaluation of ATTR cardiac amyloidosis. (1) Given the need to further evaluate for ATTR cardiac amyloidosis due to the patient's history of LVH on echocardiogram imaging, low normal ECG voltage in the absence of significant hypertension, the requested service is medically appropriate.

Therefore, the requested health service/treatment of SPECT/CT is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD
Treatment: Surgical Services (All)
The health plan denied the requested LINX service.
The health plan's determination is upheld.

This patient is a male with a body mass index (BMI (body mass index)) of 25 kg/m2 (kilogram meter squared) with a history of long-standing gastroesophageal reflux disease (GERD) despite medication intake. The patient was found to have an elevated DeMeester score of 38 on a 24-hour potential hydrogen (pH) study consistent with severe GERD. An esophagogastroduodenoscopy (EGD) revealed no esophagitis and a small hiatal hernia with retained food in the stomach; a gastric emptying study was recommended. Results of a gastric emptying study were not provided. Esophageal motility was reported to be normal.
At issue is whether the proposed health service or treatment of the LINX Reflux Management System is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination is upheld, in whole.

No. The patient does have GERD, refractory to medication, but was found to have retained food on endoscopy with a recommendation of a gastric emptying study, not available for review. Although the patient may benefit from a surgical anti-reflux procedure, which could include LINX treatment, completion of a workup to rule out gastroparesis has not been documented. At this time, it cannot be determined whether the patient will be an appropriate candidate for LINX treatment, with a recommendation to provide any updated study results to include gastric emptying study.
I uphold the denial due to incomplete medical evaluation for GERD based on reported EGD findings, which recommended a gastric emptying study for findings of retained food.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied hyaluronan injections. 
The denial is upheld.

The patient is a female with known bilateral knee osteoarthritis. The records document that she underwent successful right total knee replacement surgery. She complained of continued left knee pain and attempted a cortisone injection. The orthopedic provider requested authorization for a Synvisc one injection for this patient's left knee. The patient's health plan denied this request. At issue in this case is the medical necessity of the requested Synvisc One injection for this patient's left knee.

The requested hyaluronan injections are not medically necessary for this patient. The records document that a cortisone injection was performed on this patient's left knee. The patient had minimal improvement and the provider advised moving forward with an injection of Synvisc One. The current, peer-reviewed orthopedic literature does not support the performance of viscosupplementation injections as an effective treatment for knee osteoarthritis.
An article published by Tammachote and colleagues in the Journal of Bone and Joint Surgery was a double blinded and randomized study that compared a single injection of Hylan G-F 20 to a corticosteroid injection for patients with knee osteoarthritis. The authors concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second article published by Jevsevar and associates in the Journal of Bone and Joint Surgery concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials."
Thus, based upon the peer-reviewed literature, the performance of a viscosupplementation injection such as what is proposed for this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Surgical site infection.
Treatment: Hospital admission.
The insurer denied coverage for a hospital admission.
The denial is upheld.

The patient had a history of chronic infections to her left breast despite multiple courses of antibiotics and surgical procedures to salvage her implants. She was not septic on admission. According to MCG (Milliman Care Guidelines), 25th Edition, "General Surgery" most breast procedures can be performed on an outpatient basis. The patient did not meet any of the criteria for admission listed in the MCG, 25th Edition, "General Admission Criteria".  According to MCG General Admission Criteria: "General Criteria: Observation Care - observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable and needed only antibiotics and removal of her implants. She could have been safely managed at an observation level of care.

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

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute stroke

Treatment: Skilled nursing care

The insurer denied coverage for skilled nursing care

The denial is upheld

This is the case of a patient with Parkinson's disease who had an acute stroke. He was admitted to a rehabilitation facility for subacute rehabilitation. The following day he developed nausea/vomiting, was readmitted to an acute care hospital and underwent a cholecystectomy. He was readmitted to the skilled nursing facility (SNF) then transferred to an assisted living facility. Under review is the medical necessity of continuing skilled nursing care.

The patient was initially appropriate for the SNF subacute rehabilitation level of care. (1, 2, 3) He had functional deficits that were potentially amenable to subacute rehabilitation at the SNF level of care. Unfortunately, the treatment notes do not document evidence of significant functional improvement for the time period under review. According to the physical and occupational therapy notes, the patient continued to require maximal assistance (of 1-2 persons) for bed mobility and transfer tasks. Subsequent notes failed to documented evidence of functional improvement. According to a nursing entry, the patient "remains a total assist with all care." The physical and occupational therapy discharge notes, again document the maximal assistance needed for bed mobility and transfer tasks. There were modest gains in speech therapy for tolerating food consistencies, speech intelligibility and vocal volume; all of which did not require an SNF level of care. In addition, there were no acute medical or complicated nursing issues that required continued stay at the skilled nursing facility.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued skilled nursing care, was not medically necessary.

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

The insurer's denial of coverage for skilled nursing care is upheld. Medical Necessity is not substantiated.