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

Diagnosis: Dyspnea on exertion; Pre-hypertension. 

Treatment: Heart catheterization and ventriculography. 

The insurer denied coverage for heart catheterization and ventriculography. 

The denial is upheld. 

This is a male patient with a past medical history notable for pre-hypertension, diabetes mellitus, hyperlipidemia, obstructive sleep apnea requiring continuous positive airway pressure, and stage 2 chronic renal insufficiency. The patient went to his cardiologist with complaints of dyspnea on exertion. A recommendation was made for cardiac catheterization with possible percutaneous coronary intervention (PCI) followed by a 48-hour Holter monitor. Months prior to this, the patient had undergone stress echocardiogram which demonstrated no evidence of myocardial ischemia. 

Based on the review of the medical record and literature, there is no documentation that the patient had abnormal findings on non-invasive imaging to suggest a significant area of ischemic myocardium which would warrant invasive coronary angiography with possible percutaneous coronary intervention. There is no corroborating clinical history to indicate a high likelihood of angina as the cause of this patient's symptoms which would justify proceeding with coronary angiography and ventriculography in spite of a normal noninvasive test. Moreover, in light of the recent ISCHEMIA trial, for patients with low-risk findings on non-invasive testing, there is no difference in clinical outcomes between those referred for an invasive test (e.g. cardiac catheterization) versus those treated medically. On these bases, the use of invasive coronary angiography with ventriculography is not considered medically necessary for this patient. 

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

Based on the above, the medical necessity for the heart catheterization and ventriculography is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Status post prenatal testing.
Treatment:  Multigene Panel Test.

The insurer denied the Multigene Panel Test.  The denial is overturned in part. 

Pregnant patient received maternal genetic carrier screening with an expanded carrier screening panel.  The health plan contends that expanded carrier screening is not medically necessary unless the patient is of appropriate ethnicity for elevated risk for the diseases covered with the expanded panel.  The patient contends that carrier screening is covered under the terms "preventive care to check the health of the mother and baby during pregnancy."  No documentation is available in the information provided regarding the ethnicity of the parents nor family history regarding Fragile X related disorders or premature ovarian failure.

Yes, in part.  The multigene panel test is medically necessary, in part. 

Expanded carrier screening is not medically necessary based on the information provided, but some genetic carrier screening is medically necessary for this patient that is generally included within an expanded carrier screening panel.  Based on clinical appropriateness and known test performance in different patient populations, the American College of Obstetricians and Gynecologists has issued a practice guideline regarding the appropriateness of genetic carrier screening during pregnancy.  Genetic carrier screening is recommend for spinal muscular atrophy and cystic fibrosis for all pregnant patients, and this testing is medically necessary and generally included as part of an expanded carrier screening panel.  This testing is medically necessary.  However, any other genetic carrier screening is not medically necessary, unless the patient is known to be of an appropriate ethnic background for the diseases in question.  Fragile X testing is medically necessary only if there is a family history of fragile X-related disorders, intellectual disability suggestive of fragile X related disorders, or unexplained ovarian insufficiency or elevated follicle stimulating hormone prior to age 40.  No evidence is presented in the material reviewed that the patient was of an appropriate ethnicity nor has a family history that would meet the criteria for medical necessity for any other component of an expanded carrier screening panel than spinal muscular atrophy and cystic fibrosis.  Therefore, beyond spinal muscular atrophy and cystic fibrosis, no other genetic screening is medically necessary based on the available information.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Status post fall 
Treatment: Inpatient stay 

The inpatient stay was medically necessary, in part.

Summary:
The patient is a female. She was brought in by ambulance with complaints of back pain after slip and fall. She denied LOC (loss of consciousness).  She also c/o (complained of) left shoulder pain. 

CT scan shows L1 compression fracture.  The patient was reported to be in considerable pain and unable to ambulate without assistance. The patient reportedly lives alone. The patient was evaluated by orthopedics and found to be walking independently.  Orthopedics recommended pain management and stable for discharge. 

The patient was admitted for pain control.  PT (physical therapy) evaluated the patient.  The patient was treated with oxycodone and IV morphine.  The patient was discharged home. 

One night stay would have been appropriate. Hospital stay for one night was medically necessary to allow pain control and PT. This patient lives alone, so one night to allow her to get comfortable on pain medications, along with bracing, would have been sufficient. There was no medical indication for a prolonged stay of more than one night.  Orthopedics cleared the patient for discharge, and PT should have evaluated the patient within 24 hours and instructed on mobilization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent decay
Issue under review: D2751 - White glass with metal crown, Tooth 18

Determination:
The D2751 - White glass with metal crown, Tooth 18 is not medically necessary.

The patient is an adult female. The request is for benefits to replace crown on tooth #18.

The x-rays presented clearly show recurrent (new) decay under the existing crown on tooth #18. However, the PA (periapical) x-ray also clearly shows a radiolucency (darkening) around and under the mesial root. This darkening indicates the tooth, while having had a root canal procedure in the past, has become reinfected. Until this tooth has a "retreatment" or re-root canal procedure, it is not known whether this tooth is treatable. There is a possibility that the tooth cannot be retreated and needs to be extracted. Therefore, until a new root canal procedure is completed, and the tooth deemed "savable," there can be no benefits for a new crown at this time. If the tooth is retreated and is stable, then a new crown would be needed, but not at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Venous insufficiency and varicose veins of the right leg. 
Treatment: 37700 - Ligation and division of long saphenous vein at saphenofemoral function, or distal interruptions. 

The insurer denied the 37700 - Ligation and division of long saphenous vein at saphenofemoral function, or distal interruptions. 

The denial is upheld. 

The patient is a female with history of venous disease. There is no documentation of varicosities based on physical exam or any complications associated the varicosities and venous insufficiency. The patient has refluxing in the bilateral anterior saphenous veins. 

No, the health plan should not cover the proposed treatment. 

No, the requested health service or procedure is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease. 

The patient is a female with history of hypothyroidism, headache and venous disease according to an office note. The note states plan is ligation of the origin of incompetent branch and microphlebectomy. Venous duplex scan shows reflux of the anterior branch of the bilateral great saphenous veins. There is a piece of paper that has been check marked that the patient has pain and cramping that interferes with activities of daily living and symptoms have been increasing for years. 

The patient underwent high ligation of the left anterolateral branch of the great saphenous vein and microphlebectomy left lower extremity. The patient also underwent high ligation of accessary branch at the saphenofemoral junction and microphlebectomy right lower extremity. The patient has no complications associated the varicosities and venous insufficiency. 

The proposed treatment is not medically appropriate for this patient because: There is no specific information by the attending physician (AP) regarding patient's symptoms, its severity as well as how it interferes with activities of daily living. There is only a check mark sheet for that information. There is no documentation that the patient has tried and failed conservative therapy including wearing support stockings. Furthermore there is insufficient evidence of efficacy for the stand-alone procedure of ligation of the vein provided by the AP. The diameter of the anterior great saphenous vein was not measured. The patient has no active ulceration, bleeding, phlebitis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Venous insufficiency and varicose veins of the right leg. 
Treatment: 37700 - Ligation and division of long saphenous vein at saphenofemoral function, or distal interruptions. 

The insurer denied the 37700 - Ligation and division of long saphenous vein at saphenofemoral function, or distal interruptions. 

The denial is upheld. 

This is a female who presented with lower extremity venous disease with accompanying aching, and fatigue, as well as leg heaviness despite compression stockings which are only used during menses. Her venous duplex ultrasound (US) showed reflux of the right and left anterior lateral branch of the saphenous vein which are tortuous and not suitable for ablation. Her physical exam showed bilateral large calf and thigh varicosities. The physician is planning to ligate the origin of the incompetent anterolateral branches and perform phlebectomy of the varicose veins. 

No, the health plan should not cover the proposed treatment. 

No, the requested health service/procedure is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease. 

This patient has large varicose veins. However, per standard of care, the patient must have symptoms that interfere with activities of daily living to justify treatment of venous disease. There is no documentation that the patient has symptoms severe enough to inhibit these daily activities and therefore, they cannot be considered medically appropriate at this time. This patient would not benefit anymore from this procedure than with standard conservative therapy at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Venous insufficiency and varicose veins of the right leg. 
Treatment: 37700 - Ligation and division of long saphenous vein at saphenofemoral function, or distal interruptions. 

The insurer denied the 37700 - Ligation and division of long saphenous vein at saphenofemoral function, or distal interruptions. 

The denial is overturned. 

The patient is a female with venous insufficiency and varicose veins of the right leg. She underwent high ligation of the right anterolateral branch vein and phlebectomy. 

Yes, the health plan should cover the proposed treatment. 

Yes, the requested health service/procedure is likely to be more beneficial than any standard treatment(s) of the patient's condition. 

This patient presented with symptomatic varicose veins of the right leg. She underwent high ligation of the anterior accessory branch as well as phlebectomy. This report will review the appropriateness of the high ligation, using prevailing standards of care. 

Based on consensus guidelines for management of varicose vein disease [1], surgical intervention for axial reflux of the saphenous vein or accessory saphenous vein is medically indicated when: 
1) The patient has venous insufficiency symptoms severe enough to affect normal function. 2) The patient has failed a trial of prescription compression stockings. 3) The patient has duplex-proven reflux affecting the vein in question. 

The first criterion has been met. The office notes show that the patient's symptoms were severe enough to interfere with her normal function. The patient also completed two forms attesting to this fact. 

The second criterion has been met. The patient completed two forms attesting that she tried compression stockings as well as other conservative modalities, without improvement of her symptoms. 

The third criterion has been met. The venous reflux study showed reflux in the right anterior accessory vein. 

Based on the above discussion, the patient met well accepted criteria for surgical intervention for varicose vein disease.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal 
Surgical Services  (All) 

Diagnosis: GERD 
Treatment: Per Oral Endoscopic Myotomy 

The insurer denied Per Oral Endoscopic Myotomy. The health plan's determination is overturned. 

The patient is a female with achalasia and gastroesophageal reflux disease (GERD). She has had progressively worsening dysphagia and regurgitation, worse with solids; she failed proton pump inhibitor therapy. 

POEM is medically necessary for this patient. The American Gastroenterological Association best-practice guideline for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). Accordingly, the provider is a POEM expert (Stavropoulos, et al). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a "a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy" (ASGE PIVI Committee, et al). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al). 

This patient with severe symptoms including dysphagia, regurgitation, and unintentional weight loss, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM is supported as medically necessary for the treatment of this patient's achalasia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System /Neuromuscular disorder Multiple Sclerosis.
Treatment: Pharmacy Prescription Drugs.
The insurer denied  Requested Waiver of Ancillary Charge Associated with Coverage of Brand Copaxone.
The denial is overturned in whole.

This is a patient , who has a diagnosis of multiple sclerosis. The  patient has had a progressive decline according to her treating neurologist. The patient  was previously treated with glatiramer, interferons, intravenous immunoglobulin (IVIG), methotrexate, cladribine and mitoxantrone prior to and has been on Copaxone since.
The patient meets criteria to waive the ancillary charge associated with coverage of brand Copaxone. Based on the information provided by the patient's neurologist, the patient meets the criteria.
 The brand medication with ancillary charge will be approved without ancillary charge based on all of the following criteria:
Submission of medical records documenting patient has experienced a life-threatening, potentially life-threatening or severe adverse reaction to the generic medication which did not happen on the branded product (eg. anaphylaxis, breakthrough or an increase in seizures, hospitalization from worsening symptoms; based on switch to the generic and not attributed to other factors, adherence or change in disease state.  This criterion is met as the patient had a worsening allergic reaction to Glatopa that became severe enough for the patient to stop. The patient experienced facial flushing, heart racing, pounding, chest tightness, shortness of breath and spasms down her entire back and spine that were painful immediately after the injection of Glatopa, and had similar reactions of lesser extent with other injections of Glatopa. As she did not have symptoms with Copaxone this would be attributed to a non-active ingredient. This may worsen with additional treatment with Glatopa and cause life-threatening anaphylaxis. 
The patient therefore meets criteria for waiver of ancillary charges associated with coverage of brand-name Copaxone.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Osteoporosis.
Treatment:  Forteo.

The insurer denied the request for Formulary Exception for Forteo.  The denial was overturned.   

This male patient has a history of osteoporosis, unspecified pathological fracture presence, vitamin D deficiency, low testosterone and kidney stones.  The patient had a right femur fracture from a fall and underwent open reduction internal fixation (ORIF).  Dual energy X-ray absorptiometry (DEXA) scan results showed a spine Z-score of -2.6.  Trabecular bone score (TBS) was 1.282.  Imaging showed overall subtrochanteric fracture with persistent visualization of the fracture lucencies, new angulation, with possible fracturing at the site of angulation; and no acute osseous injury.  Referrals to genetics to rule out underlying genetic component and endocrinology were made.  The medication Forteo has been requested. 

The facts are the patient has no pain and is walking without difficulty.  These findings are consistent with a healed fracture.  A delayed union would be expected to have tenderness over the fracture site and painful walking.  The imaging studies described were significant for angulation to the distal interlocking screws.  This is indicative of fracture to the screw secondary to weight bearing and collapse of fracture.  It would be significant if clinical correlation was present.  At the very least, if the screw is symptomatic, it could be removed in the future.  The clinical findings do not substantiate necessity for additional surgery.  There is concern for the fragility fracture sustained, and an anabolic agent would be appropriate. 

A reference provided by Journal of the American Academy of Orthopedic Surgeons reports: "Pharmacologic treatments of osteoporosis include antiresorptive drugs and anabolic (bone strengthening) drugs, and those that do both.  The specific prescription depends on the extent of low bone mass (osteopenia or osteoporosis), previous low-energy fracture, risk of osteoporotic fracture, and comorbidities."

"Available treatments of osteoporosis fall into two broad classes: the antiresorptives and anabolic agents.  Antiresorptive medications inhibit the formation and function of bone-resorbing osteoclasts, thus tipping the balance of bone remodeling toward bone formation.  Anabolic agents target osteoblasts to promote bone formation.  US guidelines for osteoporosis treatment have been published by the NOF, the American College of Endocrinology."

Forteo is an anabolic agent to promote bone formation.  Based upon the insurer not providing a list of non-formulary drugs, the Forteo should be approved.  The medical history of previous fragility fracture and abnormal T scores (i.e., osteoporosis), it would be beneficial to provide an anabolic agent.  This has been shown to decrease the risk of additional fracture.

Based on the above, denial of Formulary Exception for Forteo should be reversed. Forteo is clinically appropriate for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis Benign prostatic hyperplasia
Treatment Prostate Artery Embolization
The insurer denied the Prostate Artery Embolization.
The determination is overturned.

The patient has symptomatic benign prostatic hyperplasia (BPH) and chronic urinary retention. Based on his history of coronary artery disease, discontinuation of his antiplatelet therapy was determined to be inadvisable. He was determined to be high-risk for standard surgical therapy. He has tried finasteride. He requested treatment with prostate artery embolization (PAE) which was performed. The prostate volume was 110 grams on ultrasound. At issue is whether the proposed prostate artery embolization 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 service or treatment prostate artery embolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Its use is generally accepted for this specific patient's prostate size. Its use is reasonable for this specific patient as he meets all these SIRS Guidelines (2019) and was at high-risk for a transurethral resection of the prostate (TURP) or open prostatectomy due to need for anti-platelet therapy and prostate size:
1)	PAE is an acceptable minimally invasive treatment option for appropriately selected men with BPH and moderate to severe lower urinary tract symptoms (LUTS). (Level of evidence: B; strength of recommendation: strong.)
2)	PAE can be considered as a treatment option in patients with BPH and moderate to severe LUTS who have very large prostate glands (greater than [>] 80 cubic centimeters [cm3]), without an upper limit of prostate size. (Level of evidence: C; strength of recommendation: moderate.)
3)	PAE can be considered as a treatment option in patients with BPH and acute or chronic urinary retention in the setting of preserved bladder function as a method of achieving catheter independence. (Level of evidence: C; strength of recommendation: moderate.)
4)	PAE can be considered as a treatment option in patients with BPH and moderate to severe LUTS who wish to preserve erectile and/or ejaculatory function. (Level of evidence: C; strength of recommendation: weak.)
5)	PAE can be considered in patients with hematuria of prostatic origin as a method of achieving cessation of bleeding. (Level of evidence: D; strength of recommendation: strong.)
PAE is more beneficial than TURP or open prostatectomy because the alternatives have a higher bleeding and cardiac risk. The updated 2019 SIRS Guidelines are affirmative for the safety and benefit of PAE for larger prostates.

The health plan's determination is overturned.