Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Fibroids. 
Treatment: Sonata system - radiofrequency ablation (to remove growths) - outpatient procedure (0404T x 1). 

The insurer denied: Sonata system - radiofrequency ablation (to remove growths) - outpatient procedure (0404T x 1). 
The denial is Upheld. 

The patient is an adult female with complaint of heavy vaginal bleeding. She was diagnosed with a fibroid uterus and endometrial polyps. The provider is requesting coverage for the Sonata system. 

The health plan should not cover the proposed treatment. 

There are multiple proven treatments for this patient's symptoms and findings that are more beneficial and with a longer-term track record of safety and efficiency than the requested treatment: radiofrequency ablation (to remove growths) - outpatient procedure (0404T x 1). 
The requested health service or treatment is no more beneficial than any standard treatment for the insured's condition or disease. Multiple options are available to treat fibroids including treatment with medications. In addition, a myomectomy or a hysterectomy are still considered the standard of care for managing fibroids. Myomectomies and hysterectomies have a long track record of efficacy and safety that the requested procedure does not have.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chron's Disease. 
Treatment: Stelara 90 milligrams (mg) / milliliter (ml) syringe (every 4 weeks). 
The insurer denied coverage for Stelara 90 mg/ ml syringe (every 4 weeks). 
The denial is overturned. 

The patient has Crohn's disease. The patient was previously treated with Remicade. Subsequently, the patient was started on Stelara standard dosing. The symptoms improved but a recent colonoscopy revealed active disease. Stelara level was found to be low, and the fecal calprotectin level was elevated. The physician has now requested that the patient receive Stelara every 4 weeks. 

Ollech, et. al., has an article in which data was studied from patients who initially received Ustekinumab (Stelara) every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the Ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological indices of disease activity. It was noted that dose interval shortening was effective and safe. 

This patient has Crohn's disease that was not adequately controlled on the standard every 8 weeks Stelara dose. The use of dose escalation of Stelara to every 4 weeks is supported in the medical literature. Giving Stelara every 4 weeks has been shown to be both effective and safe. 

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 Stelara 90 milligrams (mg) / milliliter (ml) syringe (every 4 weeks) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Perennial Allergic Rhinitis.
Treatment: Antigen Therapy.
The insurer denied: Antigen Therapy.
The denial is overturned.

The patient is a teenage male with a diagnosis of allergic rhinitis. The prior denial reason was no documentation of improvement while on therapy. The reason the physician is appealing the determination is to provide further documentation.

The proposed treatment was medically necessary.

The patient has a diagnosis of seasonal and perennial allergic rhinitis. His skin testing was positive to dust mite, Alternaria, tree, grass, and weed pollens. He has been on maintenance allergen immunotherapy for 2 years. Since starting immunotherapy, the patient's mother has noted that the patient, a child, has had significant improvement in his allergy symptoms from his 
baseline. A clinic note also documented that the patient has not needed to use a nasal spray consistently since he has been on shots. This addresses the denial reason. As the patient has experienced improvement of symptoms, he would benefit from continuation of allergy shots.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting/Abdominal Pain
Treatment: Inpatient level of care hospital admission 
The insurer denied: Inpatient level of care hospital admission
The denial is: Overturned.

The patient is a female who presented with vomiting and abdominal pain. She was well until 5 days prior to presentation when she developed vomiting. She had 1-2 episodes of emesis per day and also had abdominal pain localized to her central abdomen. She was seen by her primary doctor and was thought to have a viral illness. She then developed fever and stopped drinking, and therefore was brought to the emergency department for evaluation.

In the emergency department she was found to have a fever of 101.6 Fahrenheit (F) and a heart rate of 146 beats per minute (bpm). She was described as sleepy but arousable, and had a diffusely tender abdomen. Laboratory values were drawn and were significant for a glucose of 58, a carbon dioxide (CO2) of 15, and an anion gap of 22. She was given a bolus of dextrose (D)10 percent as well as 2 boluses of normal saline. A urinalysis also was obtained which was positive for ketones. An ultrasound was performed to evaluate for appendicitis and intussusception, and was reassuring but the appendix was not visualized. A chest x-ray was also obtained, and she was subsequently admitted to the hospital for further care with maintenance fluids and monitoring with a urine culture pending.
In the hospital she was kept on intravenous fluids and was monitored. She had intermittent pain and developed fever up to 103.1 F. The surgery team was consulted for bilious emesis and an upper gastrointestinal (GI) exam and kidney ureter bladder (KUB) were obtained. She later began tolerating her diet and had no further episodes of vomiting. Later, her abdominal pain resolved and she was felt to be stable for discharge with follow up as an outpatient.
The medical necessity for the inpatient level of care hospital admission is the subject under review.

The requested treatment of (inpatient level of care) hospital admission was medically necessary for this patient.
This is a patient who presented after several days of vomiting with abdominal pain, decreased oral intake, and fever. Upon evaluation she was found to have diffuse abdominal tenderness and laboratory values including a very low bicarbonate, suggesting dehydration. She received appropriate and aggressive care in the emergency department, and required subsequent hospital admission for ongoing hydration with intravenous fluids. During the hospitalization she developed bilious emesis, and required specialist consultation and further evaluation. This level of care requires inpatient admission.
This patient required inpatient care for intravenous fluids to maintain her hydration status as well as repeated clinical assessment and monitoring with additional evaluation and treatment as needed. Her clinical status worsened during the hospitalization and she required further care with specialist consultation and further evaluation in an inpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Acute onset left sided weakness and numbness associated with chest pain, shortness of breath, severe dizziness and nausea.
Treatment:  Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is overturned.

The patient is a young adult male. He presented to the emergency room with the complaint of acute onset of left-sided weakness and numbness associated with chest pain, shortness of breath, severe dizziness and nausea for two hours. The patient's neurological examination was significant for unsteady gait and collapse of left lower extremity when he attempted to walk, as well as decreased strength and sensation in his left upper extremity. CT (computed tomography) perfusion showed hypoperfusion in the region of the pons/brachium pontis. Neurology consultation recommended inpatient admission for continued telemetry and workup. There was concern for conversion disorder given psychiatric comorbidity. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was medically necessary.

Inpatient admission was medically necessary, as there was a high suspicion of stroke. According to MCG (Milliman Care Guidelines) guidelines 26th edition neurology, inpatient admission is indicated when there is progressive or severe weakness, as was the case in this patient. Although it was ultimately determined that he had conversion disorder, the decision to admit to inpatient was necessary for a stroke workup, which includes frequent neurological checks and telemetry, neither of which would be possible in the outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoxia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient is an adult with a history of alcohol abuse. Her other past medical history includes chronic obstructive pulmonary disease (COPD), asthma, hypertension and gastroesophageal reflux disease (GERD). She was brought to the emergency department (ED) after being found unresponsive in the street. The patient was also noted to be hypoxic with oxygen saturations 86% on room air. The patient was intoxicated and was suspected to have aspirated.

Vital signs at presentation: Temperature 97.7 degrees F (Fahrenheit), Pulse 88, Respirations 20, and Blood Pressure 120/84. The patient was noted to have coarse breath sounds bilaterally. The patient was sleepy but arousable. Oxygen saturations on 1-liter nasal canula were 88 -92% (percent). White blood cell count was 4.9, Hemoglobin 15.1, electrolytes within normal limits, hypomagnesemia noted. Alcohol level > (greater than) 400. The chest X-ray showed opacity to the left lower lobe with possible small effusion and possible pneumonia secondary to aspiration. The head computed tomography (CT) had no acute changes or chronic infarcts.

The patient was admitted for alcohol intoxication and possible aspiration pneumonia. The patient was treated with intravenous (IV) fluids, Thiamine, Folate and placed on Clinical Institute Withdrawal Assessment (CIWA) protocol for alcohol withdrawal. The patient was treated with Unasyn and Azithromycin.

The patient improved with treatment. By the next day, as per nursing note, the patient was in no acute distress, alert and oriented X (times) 3, was ambulatory, with no focal neurological signs. The patient was able to be switched to oral (PO) Augmentin.

This patient remained stable after admission and was discharged the next day on PO medications. This patient did not need acute inpatient hospitalization. She presented with alcohol intoxication and no definite pneumonia.

This patient could have been placed in Observation status while diagnostic studies and treatment  were initiated. This patient could have been switched to PO antibiotics and other PO medications after a period under observation (which could have been for up to 48 hours) She remained stable after admission, was afebrile and hemodynamically stable and was tolerating PO. A non-focal neuro exam was noted once she sobered up from her alcohol intoxication.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoxia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 
The patient is an adult with a history of alcohol abuse. Her other past medical history includes chronic obstructive pulmonary disease (COPD), asthma, hypertension and gastroesophageal reflux disease (GERD). She was brought to the emergency department (ED) after being found unresponsive in the street. The patient was also noted to be hypoxic with oxygen saturations 86% (percent) on room air. The patient was intoxicated and was suspected to have aspirated.

Vital signs at presentation: Temperature 97.7 degrees F (Fahrenheit), Pulse 88, Respirations 20, and Blood Pressure 120/84. The patient was noted to have coarse breath sounds bilaterally. The patient was sleepy but arousable. Oxygen saturations on 1-liter nasal canula were 88 -92%. White blood cell count was 4.9, Hemoglobin 15.1, electrolytes within normal limits, hypomagnesemia noted. Alcohol level > (greater than) 400. The chest X-ray showed opacity to the left lower lobe with possible small effusion and possible pneumonia secondary to aspiration. The head computed tomography (CT) had no acute changes or chronic infarcts.

The patient was admitted for alcohol intoxication and possible aspiration pneumonia. The patient was treated with intravenous (IV) fluids, Thiamine, Folate and placed on Clinical Institute Withdrawal Assessment (CIWA) protocol for alcohol withdrawal. The patient was treated with Unasyn and Azithromycin.

The patient improved with treatment. By the next day, as per nursing note, the patient was in no acute distress, alert and oriented X (times) 3, was ambulatory, with no focal neurological signs. The patient was able to be switched to oral (PO) Augmentin.

This patient remained stable after admission and was discharged the next day on PO medications. This patient did not need acute inpatient hospitalization. She presented with alcohol intoxication and no definite pneumonia.

This patient could have been placed in Observation status while diagnostic studies and treatment were initiated. This patient could have been switched to PO antibiotics and other PO medications after a period under observation (which could have been for up to 48 hours) She remained stable after admission, was afebrile and hemodynamically stable and was tolerating PO. A non-focal neuro exam was noted once she sobered up from her alcohol intoxication.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity/gastrointestinal esophageal reflux disease (GERD)
Treatment: Revision of prior bariatric surgery 
The insurer denied: Revision of prior bariatric surgery 
The denial is: Upheld

The patient is a female under consideration for revisional bariatric surgery. She underwent laparoscopic sleeve gastrectomy. This was performed as treatment for morbid obesity. She was able to lose 70 pounds (lbs.) following this bariatric operation. Since the sleeve gastrectomy procedure she has developed symptoms of heartburn and regurgitation. She is 64 inches tall and currently weighs 215 lbs. (body mass index [BMI] 37 kilograms per square meter [kg/m2]).

The patient consulted and has followed for the condition of refractory gastroesophageal reflux disease (GERD) post sleeve gastrectomy. The progress notes do not list any proton pump inhibitor medications or other treatment for GERD among her prescribed medications.

The subject under review is the medical necessity for the revision of prior bariatric surgery.

The request for revision of prior bariatric surgery is not medically necessary for this patient.

The proposed conversion of sleeve gastrectomy to roux-en-Y gastrojejunostomy is proposed as a treatment of GERD and as a treatment of weight recidivism. However, there is no documentation of a technical failure or a major complication of the existing sleeve gastrectomy. The esophagogastroduodenoscopy (EGD) report revealed GERD with esophagitis (per pathology report) and a small sliding hiatal hernia. The anatomy of the sleeve was described as 'quite normal.' However, the progress notes do not indicate that this patient is currently treated with medical therapy for her described symptoms of GERD. Proton pump inhibitor medications are not listed among her prescribed medications. This would be the standard initial therapy for a sleeve patient with reflux complaints. 

While revisional surgery to convert a sleeve gastrectomy to roux-en-Y gastric bypass is consistent with medical standards in the field of bariatric and metabolic surgery both for inadequate weight loss or for refractory GERD, in this case there is no indication of an anatomic abnormality of the existing sleeve and there is no documentation of medicinal treatment efforts for GERD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids and abnormal uterine bleeding
Treatment: Transcervical radiofrequency ablation (RFA) for uterine fibroids (Sonata procedure) 
The insurer denied transcervical RFA for uterine fibroids (Sonata procedure).
The determination is upheld.

This is a female patient with uterine fibroids and abnormal uterine bleeding. Her past medical history is significant for a myomectomy. A pelvic ultrasound showed 2 centimeter (cm) and 5 cm uterine fibroids. She would like to proceed with the Sonata procedure, transcervical radiofrequency ablation (RFA) for uterine fibroids. At issue is the medical necessity of the procedure.

The requested health service/treatment of transcervical RFA for uterine fibroids (Sonata procedure) is not medically necessary for this patient. The safety and effectiveness have not been established. A systematic review of prospective studies for treatment of uterine fibroids with RFA has been completed. The authors concluded that RFA of uterine fibroids significantly reduced fibroid volume, provided significant durable improvements in fibroid-related quality of life (QOL), and was associated with favorable re-intervention rates. However, there were several drawbacks pertaining to the quality of the included studies that may influence conclusions. First, there was less precision in the RFA results following 12 months of follow-up since fewer studies reported longer term data. Second, the number of included studies was insufficient to perform statistical comparisons among RFA delivery approaches for several outcomes. Third, it was not possible to determine from this analysis whether RFA efficacy was influenced by fibroid type or volume due to concerns of aggregation bias whereby real associations observed at the patient level. Finally, these researchers planned to report the frequency of complications in this meta-analysis; however, complication reporting was highly inconsistent and inadequate such that any attempts at reporting these data would have led to inaccurate and misleading results. These investigators stated that authors of future RFA studies are encouraged to provide detailed definitions of complications and a complete listing of reported complications during follow-up, with further specification of event seriousness and relationship to the RFA procedure. There are no current guidelines support its use over standard therapy at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld.

The patient is a male with a past medical history significant for hypertension, coronary artery disease, status post-drug-eluting stents, formal tobacco use, and asthma who presented to the hospital with left-sided chest pain. The pain started the evening before his presentation. The patient described the pain as severe, radiating to the left arm. It was associated with shortness of breath. Apparently, the patient stopped taking Plavix 2 weeks before this episode due to a tooth extraction.

The patient was admitted to the hospital with chest pain to rule out acute coronary syndrome. The patient received treatment with intravenous fluids due to the elevation of creatinine levels.
In the hospital, the patient was seen by a nephrologist who stated that the patient had a history of chronic kidney disease stage III, nonfunctioning kidney due to injury, hypertension, and coronary artery disease.
In the hospital, the patient was seen by a cardiologist who recommended outpatient ischemic evaluation.
As far as elevated creatinine levels, the patient's creatinine went down from 1.68 to 1.5. According to the nephrologist, those levels were close to the baseline. The patient was recommended to follow up as an outpatient.
The patient continued to receive treatment with bronchodilators considering his history of asthma. Although, he had a normal respiratory rate and normal oxygen saturation on room air. During the hospital stay, the patient remained in stable clinical condition and was transitioned to outpatient care.

The inpatient hospital admission was not medically necessary.
The patient presented to the hospital with chest pain that was not associated with hemodynamic instability or significant respiratory distress. There was no clinical evidence that the patient had angina or myocardial infarction. There was no need for any cardiac intervention based on the evaluation performed by the cardiologist. The chest pain was not indicative of a serious diagnosis other than coronary artery disease. The elevated creatinine level was rather consistent with previously diagnosed chronic kidney disease and did not meet the definitions of acute kidney injury.
While the patient's chest pain was not indicative of a serious diagnosis other than coronary artery disease, the patient's previous history of coronary artery disease increases the risk of acute coronary syndrome. Moreover, the evaluation performed by the cardiologist did not warrant any immediate cardiac intervention, but it is important to rule out any dangerous reasons for the chest pain, especially given the patient's history. The elevated creatinine level was consistent with previously diagnosed chronic kidney disease and did not meet the definitions of acute kidney injury, which suggests that the patient's condition was stable. Overall, while the patient did not require admission at the acute inpatient level of care, a lower level of care status would have been appropriate for the management of the patient's condition.