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

Diagnosis: Uterine leiomyoma.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

The patient has history of menorrhagia and symptomatic fibroids. She underwent
a planned laparoscopic supracervical hysterectomy bilateral salpingectomy with sacrolpopexy, lysis of adhesions, and placement of midurethral sling with cystoscopy. 
 
The procedure was reported as uncomplicated. Post-operatively the patient was stable. There was no report of any post-operative complications.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic supracervical hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary. According to Milliman Care Guidelines, Inpatient and Surgical Care 17th Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:
Surgical complications (bladder ureter or bowel injury or hemorrhage), Conversion to abdominal hysterectomy, Complex surgery (staging of endometrial cancer), Wound complications and Comorbidities. This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. Please note that this patient had a supracervical hysterectomy. In other words, the vagina was not entered, and the procedure is much less invasive than a total hysterectomy. So, recovery period and complications should be much less than with a total hysterectomy.
Based on above, the inpatient admission was not medically necessary.

The inpatient admission is not considered medically necessary for this patient. 

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

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

Diagnosis: Head/facial pain
Treatment: Ambulance transfer
The insurer denied ambulance transfer. 
The health plan's determination is upheld. 

The patient is a woman who presented to the hospital with head and facial pain. The patient had neurologic symptoms associated with the headache including a visual field cut, right-sided numbness and tingling, and tremulousness. These symptoms resolved by the time of presentation to the emergency room. The emergency room physician documented a normal physical examination. The patient was evaluated by teleneurology for "transient ischemic attack (TIA) symptoms" and it was recommended that she undergo magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) of the brain. The patient was transferred to a different hospital for further evaluation by ambulance. The ambulance transportation is the subject of this review.

The requested Ambulance Transportation is not medically necessary. The patient presented to the hospital with headache and transient neurologic symptoms. The patient had no neurologic symptoms at the time of evaluation. The patient was evaluated by teleneurology and imaging was recommended including MRI brain, MRA head and neck, and MRV brain.
The physician assistant initiated a transfer to another medical facility. However, the indication for transfer was not documented in the evaluation. According to the sending facility, MRI is available to inpatients. As such, there is not a compelling reason why the recommended imaging could not be performed. For the diagnosis of transient ischemic attack, there is no indication for emergent imaging. Imaging, when performed, is generally done in a routine fashion because the patient is stable and without neurologic deficit.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, hypertension, spinal stenosis, and coronary artery disease 

Treatment: Consumer Directed Personal Assistance Program (CDPAP): 7 hours per day- 7 days per week- for a total of 49 hours per week

The insurer denied coverage for CDPAP: 7 hours per day- 7 days per week- for a total of 49 hours per week

The denial is upheld

The patient has chronic medical problems including diabetes mellitus, hypertension, coronary artery disease and spinal stenosis. She lives in a 4-bedroom house with her daughter and son-in-law. She is currently approved for CDPAP 5.5 hours per day- 7 days per week- for a total of 38.5 hours. Under review is the requested increased CDPAP: 7 hours per day- 7 days per week- for a total of 49 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognitive ability is only "minimally impaired." She is otherwise alert and oriented. She requires extensive assistance for activities of daily living tasks including bathing, personal hygiene, dressing and toilet transfers. She is incontinent of bladder and continent of bowel. There have been no reported hospitalizations or falls over the prior 90 days. The clinical records do not support a level of cognitive impairment or significant functional decline to support the medical necessity of increasing CDPAP: 7 hours per day- 7 days per week- for a total of 49 hours per week.

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

The insurer's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP): 7 hours per day- 7 days per week- for a total of 49 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Atopic Dermatitis, Alopecia Areata
Treatment: Rinvoq
The insurer denied the Rinvoq.
The determination is upheld.

The patient has atopic dermatitis. He also has alopecia areata. He has tried and failed intralesional kenalog. The medication under revew is Rinvoq. At issue is whether Rinvoq is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health treatment Rinvoq is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the standard of care medications, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis (1, 2).
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults" (3).
It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred medications which have been shown to be effective for the treatment of atopic dermatitis. The conventional agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The standard of care medications should be tried and failed prior to initiating Rinvoq. Therefore, Rinvoq is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic anemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

This is the case of a female with a diagnosis of uterine fibroids who was admitted to the emergency room with vaginal bleeding. Her vital signs were normal on admission. She was noted to be alert and oriented on admission. She denied shortness of breath, chest pain or palpitations. The patient also had a diagnosis of diabetes, seizures, and an intellectual disability. A hemoglobin was 4.6. She was admitted to the inpatient service for a transfusion. She was transfused blood. The patient was described as having dizziness on admission which continued after one unit transfusion while in observation. Two seizures were later witnessed during the inpatient stay. She then underwent a tonic-clonic seizure with neurology consulted. She was determined to have a seizure due to severe anemia. She was discharged. 

The medical records and medical literature were thoroughly reviewed. The patient was admitted as an inpatient for symptomatic anemia. She had multiple co-morbidities including a seizure disorder which was exacerbated by her severe anemia. The patient required an acute level of care as an inpatient due to these co-morbidities and the continued symptomatic anemia despite transfusion. Therefore, the inpatient stay was within the standard of care and medically necessary.

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 the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

This is a male with a history of asthma, duplicate kidney collecting system, and a history of patent ductus arteriosus closure. He presented to the hospital emergency room for fever and lethargy. He received intravenous (IV) antibiotics, diagnostic testing, laboratory testing, and medications. 

The patient has multiple complicated diagnoses and presents with fever, vomiting, high white blood cell (WBC) count of 30k (thousand) and high acute phase reactant level. The blood culture grew Methicillin resistant Staphylococcus Aureus (MRSA). The patient has a history of sepsis. The risk of endocarditis and meningitis from secondary embolization is medium to high. The patient also has a poor pulmonary reserve and was at risk of complicated pneumonia. Hence, patient would need close and persistent monitoring in the Intensive Care Unit (ICU) or stepdown for neuro checks and cardiorespiratory monitoring. 

Hence, 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 an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

This is a woman that presented to the hospital complaining of back pain radiating down her left leg. Upon arrival to the emergency department (ED) she was hypertensive with a BP (blood pressure) of 246/138 mmHg (millimeters of mercury). Physical examination revealed no evidence of abnormality. Serum blood testing was significant for an elevated creatinine of 1.6mg (milligram)/dl (deciliter). 12 lead electrocardiogram revealed normal sinus rhythm with APCs (atrial premature complexes) and no ST (interval on an echocardiogram (ECG)) or T wave (interval on an ECG) abnormalities. Following treatment with nifedipine and hydralazine the patient remained hypertensive (219/124 mmHg). She was admitted to the hospital and treated with intravenous labetalol. She was discharged once blood pressure was controlled on oral medications. 

The health care plan did not act reasonably with sound medical judgment and in the best interest of the patient. Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) This patient had an elevated serum creatinine consistent with acute renal insufficiency. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Given this patient's failure to respond to initial medical therapy, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU (intensive care unit) for management of hypertensive emergencies (Reference 1). In conclusion this patient should have been managed at a higher level of care. 

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 hospital; admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral Neuropathy
Treatment: Outpatient Procedure (63650x 2 & 95972 x 1)
The insurer denied the Outpatient Procedure (63650x 2 & 95972 x 1)
The denial is overturned

Patient is a female with small fiber neuropathy. She has undergone an extensive work up. She has failed multiple neuropathic medications, she has failed pain medication. She has underwent nerve blocks, she has done physical therapy. Thus far she continues to have severe lower extremity pain. This has been confirmed on EMG (electromyography) as well as skin biopsy. Exam is consistent for neuropathic pain. A spinal cord stimulator has been recommended. This was denied as being not medical necessary.

Yes, the proposed treatment is medically necessary.

Thus far conservative treatment has been ineffectual. The patient has tried multiple medications that are useful for neuropathic pain. Spinal cord stimulation is often used in treatment of neuropathic pain conditions such as post laminectomy syndrome, complex regional pain syndrome, diabetic neuropathy and peripheral neuropathy. Multiple studies have shown effectiveness in diabetic neuropathy, which from a pathology and a pathophysiological standpoint is not dissimilar to peripheral neuropathy of non-diabetic origins. Given that this patient has a case of severe refractory peripheral neuropathy that has not responded to conservative treatment, spinal cord stimulation is reasonable.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral (Intracept).
The insurer denied coverage for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral (Intracept).
The denial is upheld

This is the case of a male with a history of lung cancer, cervical myelopathy and chronic back pain. He presented to the nurse practitioners office reporting sharp back pain with radiation down his bilateral lower extremities. He reports pain increases with sitting, standing, walking, and bearing down. The office note reports he has failed conservative measures. A magnetic resonance imaging (MRI) of the spine showed multilevel degenerative disc disease, spinal canal stenosis, and neural foraminal narrowing. A circumferential disc bulge eccentric to the right at L (lumbar) 3/4 effacing the right lateral recess and abutting the descending right L4 nerve root. A left paracentral disc bulge at L4/5 effacing the left lateral recess and compressing the descending left L5 nerve root. There was no cord compression or an abnormal cord signal. The Intracept procedure was recommended.

The Intracept procedure is "intraosseous ablation of the basivertebral nerve". It has been proposed to address low back pain identified by Mobic changes. 

The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients and no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons nor spine surgeons. There are no National Organizations which provide guideline nor indication. 

The procedure is essentially a thermoablation performed within the vertebral body. 
There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. 

The clinical facts of this case also do not clearly define the pain generator. The man has chronic back pain and has been treated for a multitude of diagnoses. The facts are his imaging studies show dramatic changes not confined to a "vertebrogenic" source of pain. He has instability, compression fractures, stenosis and nerve root compression. Performing this type of operation will not likely change his pain. The determination is not likely to be more beneficial than any other standard procedure without increased risk over other surgical procedures.

The carrier's denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophagitis/hernia. 
Treatment: Inpatient Stay. 
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

This patient is a woman who presented to the hospital with the diagnosis of Grade C esophagitis, Barrett's and a paraesophageal hiatal hernia. She underwent laparoscopic repair of the paraesophageal hiatal hernia, Nissen fundoplication and intraoperative endoscopy. She was admitted to the hospital. 

An inpatient level of care was medically necessary. 

This patient had a paraesophageal hiatal hernia and underwent operative repair and fundoplication. The operative dictation describes the mobilization of the distal esophagus, crural repair and fundoplication. Four crural stitches were used to reapproximate the diaphragmatic crura. The patient was initially nothing by mouth (NPO) after surgery and she was monitored for dysphagia, pain, and nausea. She was provided antiemetic medications and parenteral analgesia. 

An inpatient level of care is consistent with generally recognized standards of care for the condition of a paraesophageal hiatal hernia as documented to exist in this case. This patient had comorbid health conditions of hypertension, and hyperlipidemia. She underwent an operation that carried the reasonable expectation of hospitalization for at least 2 midnights (48-hours). The anticipated length of stay, the diagnosis of paraesophageal hiatal hernia and the intensity of service provided in this case support an inpatient designation. 

Based on the presurgical diagnosis, the anticipated length of stay, and the need for post-surgical monitoring, a physician exercising prudent clinical judgment would admit this patient to an inpatient level of care. This level of care is in accordance with generally accepted standards of medical practice.
Appeal type: Medical necessity
Decision: Upheld

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

The patient was admitted for hypertension urgency and was treated with antihypertensive. She was also found to have hyperkalemia and acute kidney injury and was treated with intravenous (IV) fluid. She was discharged in stable condition. This patient was noted for abnormal kidney function; however, her condition was responding to IV fluid which was more consistent with prerenal azotemia and there were no signs of severe renal damage or not immediately reversible condition such as vasculitis or ischemic acute tubular necrosis. She was also noted to have hyperkalemia but without severe cardiac arrhythmias.

Her condition could have been safely treated under a lower 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 inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Procedure code 62323, pain injections. 

The insurer denied coverage for procedure code 62323, pain injections. 

The denial is upheld. 

This male has a history of lower back pain. The patient takes oxycodone with tolerable relief. He was treated with multiple epidural steroid injections (ESI) in the past with good relief. The physician requested epidural steroid injections (ESI) to treat back pain. 
The insurer has denied coverage for procedure code 62323, pain injections, as not medically necessary. They stated that the patient was already treated for months with 4 injections. The patient has had multiple epidural steroid injections for several years. 

Hassan and Shermam (2) have stated: "Epidural steroid injections can be safely injected 3-4 times per year, with a minimum duration of at least two weeks between two injections. Often, two to three injections need to be done to effectively alleviate the pain. If the injections are not providing significant relief, a discussion with the healthcare provider is warranted to discuss further treatment options." 

This patient is at risk of decreased bone density because of the number of epidural steroid injections received and cumulative dosage of steroids administered. The request exceeds standard frequency guidelines. 

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

The insurer's denial of coverage for procedure code 62323, pain injections, is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Taltz. 
The denial is upheld.

The patient is a female with psoriasis and psoriatic arthritis. She has axial involvement. She has failed clobetasol ointment, and naproxen. The subject under review is the medical necessity for Taltz.

Taltz is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred alternatives Enbrel, Humira, Renflexis, Inflectra or Avsola.
According to the American Academy of Dermatology Psoriasis Guidelines and medical literature, the preferred medicines such as Humira and Enbrel covered by the health plan are effective treatments for the management of psoriasis and psoriatic arthritis (1, 2). Within the peer-reviewed literature, according to Burness et al., "well-designed randomized clinical trials demonstrated that adalimumab 40 milligrams (mg) every other week (eow) effectively reduced the signs and symptoms of psoriasis and improved dermatology-specific and general measures of health-related quality of life, with these benefits sustained during long-term treatment" (3). Mease et al. writes "Adalimumab significantly improved joint and skin manifestations, inhibited structural changes on radiographs, lessened disability due to joint damage, and improved quality of life in patients with moderately to severely active psoriatic arthritis (PsA)" (4). The plan preferred agents are appropriate agents for the treatment of the patient's psoriasis and psoriatic arthritis.