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

Diagnosis: Blind, asthma, cerebrovascular accident (CVA), hemiplegia, gastroesophageal reflux disease (GERD), osteoarthritis

Treatment: personal care services - 24 hours a day, 7 days a week (split shift) totaling 168 hours per week

The insurer denied coverage for personal care services - 24 hours a day, 7 days a week (split shift) totaling 168 hours per week

The denial is overturned

 
The patient is diagnosed with asthma and has had some recent cardiac symptoms without etiology. Her primary care physician notes she is completely blind-presumably due to glaucoma, and has new left sided weakness as of this year. The patient had cervical magnetic resonance imaging (MRI) performed.  The Uniform Assessment System (UAS) notes she needs maximal assist for weight bearing, toilet use & transfer, is frequently incontinent of urine, limited solid food intake, sips liquids, able to walk less than 15 feet and uses a walker. She has no informal helpers although this is unclear since in some areas it indicates she gets assistance from family members. She needs assistance with incontinence of bowel and bladder throughout the day and night. She cannot use toilet by herself. Personal care services (PCS) are being requested for 24 hours per day, seven (7) days per week (split shift), totaling 168 hours per week, which is under review.

"When friends and family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care" (D'Cruz, L., et al. 2022).

"Millions of older adults and adults with chronic conditions and disabilities in the United States depend on home care workers to remain at home and age in place. Home care workers, which include home health aides, attendants, and personal care aides, provide assistance with personal care (activities of daily living and instrumental activities of daily living), medically oriented care, and emotional support" (Shaw, A. L., et al. 2022).

"The Future of Home Health Care states that one of the "pillars" of home healthcare should be "patient/person-centered care." They define patient-centered care using the definition in Crossing the Quality Chasm: "Patient-centered care (PCC) is providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" (Institute of Medicine [IOM], 2001, p. 3; Landers et al., 2016, p. 272)" (Narayan M. C. 2022)

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care services - 24 hours a day, 7 days a week (split shift) totaling 168 hours per week is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: VIA Disc NP (Procedure Code 0627T). 
The insurer denied VIA Disc NP (Procedure Code 0627T). 
The health plan's determination is upheld. 

The patient is a female with complaints of chronic low back pain. The pain is in the midline. Imaging demonstrates disc degeneration at the L (lumbar) 4-L5 level. Pain impacts activities of daily living (ADL). She has trialed tramadol as well as muscle relaxants. Prior treatments have included physical therapy as well as injections. 

The VIA Disc is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The provider is requesting Via Disc NP for lumbar degenerative disc disease. This type of procedure is not recommended due to lack of support in the medical literature. The research has been fraught with bias and sloppiness. Major questions remain unanswered regarding the best cell type and origin (peripheral blood, bone marrow, fat, or even allogeneic umbilical cord), cell dosage, timing, single versus multiple treatments, and carrier biomaterials (hyaluronic acid, tissue scaffolds). Overall, VIA Disc is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: VIA Disc NP (Procedure Code 0627T). 
The insurer denied VIA Disc NP (Procedure Code 0627T). 
The health plan's determination is upheld. 

This is a female patient diagnosed with Vertebrogenic Low Back Pain. The records provided indicate the patient was recommended to undergo the VIA Disc procedure, which was denied by the insurance carrier as experimental and investigational as there is insufficient evidence that this treatment improves health. 

VIA Disc is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The patient is noted have a history of chronic back pain that has not responded to conservative treatment, medications, or injections. The patient is noted to have multiple significant findings on magnetic resonance imaging (MRI) and likely multiple pain generators. The patient was recommended to undergo the VIA disc treatment, however this is not standard of care. In 2020, the North American Spine Society, along with 9 other societies, published multidisciplinary evidence-based guidelines on the diagnosis and treatment of low back pain. There was insufficient evidence to make a recommendation for or against the use of intradiscal bone marrow concentrate in patients with discogenic low back pain, and no review of intradiscal allograft injection. Per Romaniyanto et. al, "The aim of current therapeutic approaches is to delay the degeneration process and stimulate IVD (intervertebral disc) regeneration to give more resilient outcomes with various mechanisms. There are methods developed for the current approach in IDD (intervertebral differential dynamics), which are using growth factors, small molecules, gene therapy, and stem cells. These methods have their own challenges and limitations, such as survival of the factors in IVD environment to create a regeneration effect; infection and mutation due to the viral vector effects in delivering the gene target; and costs. Clinical studies in humans are still in progress by taking into account safety, duration of treatment, individual approach. These are a promising therapeutic approach but still needs further research to be applied in clinical."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: VIA Disc NP (Procedure Code 0627T). 
The insurer denied VIA Disc NP (Procedure Code 0627T). 
The health plan's determination is upheld. 

The patient is a female who has chronic axial low back pain. Her pain is worse with prolonged sitting and activities. She describes her pain as constant sharp and aching. She had tried physical therapy (PT), home exercise, pain medications, and lumbar spinal injections with minimal improvement. She is on Tramadol, which takes the edge off. Her pain level is 8/10. Physical exam (PE) showed decreased range of motion (ROM), and pain with lumbar flexion. Magnetic resonance imaging (MRI) revealed diffused disc bulges and facet arthropathy from L (lumbar)2 to S (sacral)1, and severe spinal stenosis at L4-5 from diffused disc bulge, facet hypertrophy, hypertrophy of ligamentum flavum and epidural lipomatosis. 

VIA Disc is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
There is strong clinical evidence to show sustained improvements in pain and function of VIA disc for one or two level discogenic pain. However, this patient has diffused degenerative disc disease and facet arthropathy from L2 to S1 with severe stenosis at L4/5. In the Randomized Controlled Trial by Beall, "patients with spondyloarthropathies, prior lumbar spine surgery, Modic type 3 endplate changes, greater than mild facet joint arthrosis, or spinal stenosis were excluded". Based on the exclusion criteria of the current clinical study and this clinical presentation, the requested Via disc injection at L4-5 is not likely to be more beneficial than standard treatments for the insured's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Guillain Barre Syndrome. 
Treatment: Wheelchair ramp. 
The insurer denied coverage for the wheelchair ramp. 
The denial is overturned. 

This is a patient diagnosed with likely Guillain Barre Syndrome (GBS) with associated severe weakness. The patient needs assistance from others for transfer activities, is wheelchair dependent and non-ambulatory. The patient lives in an apartment and has 1 step to enter and exit the building. Under review is the medical necessity of requested wheelchair ramp. 

The requested ramp is clinically appropriate and medically necessary for this individual who has severe weakness due to neuropathy. This review is in agreement with the patient's treating physician regarding the medical necessity of the requested outdoor ramp. The patient's lack of proper home accessibility demonstrates a significant safety issue. In addition, the requested environmental modification for the ramp installation provides emotional well-being and a lifeline for adaptive home ingress/egress. Contrary to the assertion of the insurer, the requested ramp would indeed assist the patient with greater independence, particularly for access to social services and other community resources. 

The healthcare plan acted did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested wheelchair ramp is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for wheelchair ramp services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Wegovy 0.25 MG (milligrams)/0.5 ML (milliliters) SC (subcutaneous) SOAJ (solution auto injector)

The insurer denied coverage for Wegovy 0.25 MG (milligrams)/0.5 ML (milliliters) SC (subcutaneous) SOAJ (solution auto injector)

The denial is overturned
 

This is an adult male diagnosed with Obesity. This request is for Wegovy. As per letter; he tried and failed diet; exercise and stress management. His weight went down from 205 to 195 pounds which is 4.8 % (percent) of weight. 

Semaglutide is a glucagon like peptide 1 receptor (GLP1R) agonist(1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity(5-7). This medication is now available for the treatment of obesity in the form of Wegovy. 

The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a Body Mass Index (BMI) of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, hyperlipidemia. The patient has been participating in lifestyle modifications and the patient's BMI is 31. The request does meet the standard of care and is therefore medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Wegovy 0.25 MG/0.5 ML SC SOAJ is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus with viral infection

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Reversed

This is a pediatric patient with a history of severe persistent asthma who had been coughing with nasal congestion for 3 days. The patient had been last admitted to the PICU with asthma 3 months prior to this admission. The patient had been intubated for respiratory failure related to asthma on 2 previous occasions and has had a history of daily asthma symptoms, limited activity and the need for daily treatments with Albuterol. The patient had been prescribed inhaled steroids for daily preventive therapy by a consulting pulmonologist during a previous admission, but this medication was not started. When the patient developed a fever and difficulty breathing his mother contacted Emergency Medical Services (EMS) to bring him to the Emergency Room (ER) for additional treatment. During transport to the ER the EMS worker administered a Combivent treatment.

In the ER the patient was noted to be in respiratory distress with expiratory wheezing, prolonged expiratory phase of respiration and an increased respiratory rate with intercostal retractions. Treatment included: Epinephrine, Duoneb treatments, Solumedrol, Magnesium Sulfate and an intravenous (IV) bolus of normal saline. A chest radiographic image (x-ray) showed interstitial edema and a blood gas showed a respiratory acidosis with a potential of hydrogen (pH) of 7.29 and a partial pressure of carbon dioxide (pCO2) of 53. In view of the chronic nature of the poorly controlled asthma, non-compliance with prescribed asthma preventive therapy and respiratory acidosis documented on a blood gas the decision was made to admit the child with a diagnosis status asthmaticus for continued treatment with albuterol every 3 hours.

The patient was treated appropriately in the Emergency Room (ER) for an acute episode of wheezing, and difficulty breathing. The child has a history of 2 previous admissions to the pediatric intensive care unit (PICU) and intubations for asthma induced respiratory failure. The plan for continued treatment with albuterol every 3 hours could not have been safely administered at home because of the respiratory acidosis and retention of carbon dioxide (CO2) documented on the blood gas. The admission to the hospital was appropriate and consistent with the standard of care for respiratory acidosis in a child who has previously required intubation for status asthmaticus on 2 occasions.

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

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain
treatment: inpatient stay
the insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman with hypertrophic cardiomyopathy, status/post (s/p) implantable cardioverter defibrillator (ICD) placement, and atrial fibrillation who presented to the emergency room with chest pain radiating to her jaw, palpitations, dizziness, and dyspnea. She had stopped medications on her own, including metoprolol, verapamil, and Eliquis, a week prior to presentation. Heart rate was 135 beats per minute (bpm), blood pressure (BP) 100/82 and respiratory rate 17. Oxygen saturation was 99% (percent). She was found to be in atrial fibrillation. She had mild elevation of high sensitivity troponin- 109 then 95.
She was admitted and an echocardiogram (ECHO) performed showing left ventricular hypertrophy and ejection fraction (EF) greater than 75%, as well as hyper -dynamic function. 

An inpatient admission is not medically necessary. The patient presented with chest pain and dyspnea, due to rapidly conducted atrial fibrillation. She was treated with intravenous medication with control of rate and symptoms within the first 48 hours of observation. She does not meet criteria for inpatient admission per standard guidelines, including Milliman Care Guidelines. She did not have hypotension, persistent symptomatic tachycardia despite observation care, acute myocardial ischemia that persists despite observation care (eg, rate control), altered mental status, syncope, congestive heart failure (CHF), medication toxicity, ICD shocks or other underlying medical condition necessitating inpatient care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Septal Deviation, Nasal Valve Collapse, Acquired Deformity of Nose, Hypertrophy of Both Inferior Nasal Turbinates, Nasal Obstruction, Nasal Congestion
Treatment: Repair of Nasal Vestibular Stenosis (CPT 30465)
The insurer denied the Repair of Nasal Vestibular Stenosis (CPT 30465)
The health plan's determination is overturned.

The patient is a male who underwent septoplasty, turbinate reduction, and open repair of nasal valve/vestibular stenosis using spreader autologous harvested septal cartilage grafts. He had symptoms consistent with nasal congestion/obstruction. The nasal endoscopy and clinical examination were consistent with nasal valve stenosis, deviated septum, and turbinate hypertrophy. He underwent maximal medical therapy, including intranasal corticosteroids without improvement in his symptoms.

At issue is the medical necessity of Repair of Nasal Vestibular Stenosis (current procedural terminology (CPT) 30465).
I overturn, in whole, the health plan's determination of medical necessity.

The requested service/treatment of repair of nasal vestibular stenosis is medically necessary for this patient.

The patient has been diagnosed with internal nasal valve collapse, deviated septum, and turbinate hypertrophy. He has persistent nasal congestion despite trying maximal medical therapy. In order to improve his nasal airway and alleviate his symptoms of nasal congestion, the patient requires the above procedures proposed. The patient has completed maximal medical therapy for nasal congestion/obstruction, including using intranasal corticosteroids, nasal strips, and a thorough clinical examination and an in-office nasal endoscopy. Given that the patient had numerous anatomic causes for persistent nasal congestion/obstruction, including nasal valve stenosis, the proposed health service/treatment repair is likely to be more beneficial than standard medical care.

The plan is proposing that the patient first undergo septoplasty and turbinate reduction prior to the consideration of nasal valve repair/functional rhinoplasty. This is not reasonable nor is it standard of care. Given the presence of nasal vestibular stenosis, standard septoplasty and turbinectomy would likely be insufficient for adequate control of symptoms without the additional of open functional septoprhinoplasty. In addition, cartilage is often harvested from the septum for use during the nasal valve repair/open functional rhinoplasty; separating the 2 surgeries would unfortunately result in an ability to use a septal graft harvest which is often times critical to the success of this operation. Furthermore, the patient does meet appropriate criteria, both by clinical standard and by the health plan's written criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain; chills
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with diabetes. She is a smoker with candidiasis. She presented to the hospital with flank pain and chills. The patient was noted to have a urinary tract infection. The patient was treated with antibiotics and fluids along with pain control. The health plan's denial of coverage of the inpatient 
admission is being appealed.

The Inpatient admission was not medically necessary.

The patient presented to the hospital with flank pain, chills, and elevated blood glucose levels. She was treated for a urinary tract infection. Based on MCG (Milliman Care Guidelines) criteria, admission is indicated for "Hemodynamic instability, Vomiting that is severe or persistent, Altered mental status that is severe or persistent, Persistence or worsening of clinical findings despite observation care treatment, Parenteral antibiotics needed beyond observation care treatment, Pregnancy with suspected pyelonephritis, renal transplant recipient with pyelonephritis, significant uropathy, bladder emptying impaired, renal or perinephric abscess."
Admission may be indicated for "suspected infection of a prosthetic device, renal failure, acute kidney injury, or need for IV (intravenous) hydration support or other condition, treatment, or 
monitoring requiring inpatient admission." Based on available data, the above criteria were not met in this patient's scenario. Therefore, the requested dates of services were not medically necessary at an inpatient level of care. The patient 
could have been safely and effectively managed at a lower level of care. The request would not be considered medically necessary as it was not the least intensive and/or most appropriate alternative among diagnostic and treatment options for the patient, as a lower level of care would have been clinically appropriate. Therefore, the inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Neurocardiogenic syncope.
Treatment: Leadless pacemaker
The insurer denied a Leadless pacemaker.
The determination is upheld.

This is a male patient with a history of neurocardiogenic syncope. He has had multiple syncopal episodes with resultant bodily injuries. He had a tilt test with 15 seconds of asystole. He had a structurally normal heart by echocardiogram, normal nuclear stress test, and no significant arrhythmias on a 5-day ambulatory monitor. A permanent pacemaker was recommended. In view of his relatively young age, and likely need for repeated battery replacements with risk of infection, the provider recommended a leadless pacemaker. At issue is whether the leadless pacemaker is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The treatment, based on current literature including the article from the provider, shows that efficacy of the leadless pacemaker is as effective as the pacemaker with a lead, i.e. the standard permanent pacemaker (PPM). Some data suggest a lower incidence of complications at one year. However, there is very little data that long-term outcomes are superior with leadless pacemaker compared with PPM. The rationale that the leadless pacemaker would inhibit the patient's activity less than a PPM with a lead is not totally convincing as very active people do quite well with a PPM with a lead. In view of the intermittent use of the implanted pacemaker in this patient and his age, there would not appear to be an excessive number of battery changes. Although a leadless pacemaker is a reasonable alternative, it is less convincing that it is preferable in this patient. A PPM with a lead would be an acceptable treatment for this patient.