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

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a female who presented to the emergency department complaining of three weeks of intermittent chest pain, palpitations and dyspnea. Her medical history was remarkable for recurrent ovarian cancer. Her blood pressure was 137/75 millimeters of mercury (mmHg) with a heart rate of 100 beats/minute. Her respiratory rate was 22/minute with a room air oxygen saturation of 98%. Her cardiac and pulmonary exams were unremarkable. An electrocardiogram showed sinus rhythm without acute ischemic changes. The patient's serum troponin level was normal. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. The patient's hemoglobin level was 8.9 grams per deciliter (gm/dl). Testing for Covid-19 was negative. She was admitted to the hospital for "further cardiac workup". The following day the patient had no complaints. An echocardiogram showed normal left ventricular systolic and diastolic function. Myocardial perfusion imaging showed no evidence of ischemia. Discharge was planned but the patient developed repeated episodes of vomiting, possibly related to her treatment with niraparib for ovarian cancer. Her vomiting did not resolve with ondansetron and metoclopramide. She was treated with intravenous fluid and compazine. The next day she was improved and was discharged. Medical necessity for an inpatient stay is at issue. 

The health plan's determination is upheld in whole. 

An inpatient stay was not medically necessary. This patient was admitted with chest pain that was thought to possibly represent acute coronary syndrome. She was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. 
The Milliman Care Guideline, Chest Pain (ORG: M-89) was reviewed. Per this document indications for inpatient admission include hemodynamic instability (NOT MET), respiratory distress (NOT MET), chest pain indicative of serious diagnosis other than coronary artery disease (NOT MET) and angina or myocardial infarction. The reader is referred to guidelines for angina or myocardial infarction. However, the patient did not meet accepted clinical criteria for a diagnosis of myocardial infarction. 

The inpatient stay was not medically necessary, and the patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Advanced Imaging. 
The insurer denied: Myocardial Perfusion Imaging. 
The denial is overturned in whole. 

The patient is a male with hypertension and recently diagnosed atrial fibrillation. he was evaluated for intermittent episodes of chest pain and exertional dyspnea. His electrocardiogram showed atrial fibrillation with a ventricular rate of 83 beats/minute. There were nonspecific T wave abnormalities. The patient underwent exercise stress testing. His rhythm showed atrial fibrillation with a resting ventricular rate of 105 beats/minute. There were baseline ST segment abnormalities. The test was stopped during stage I of the Bruce protocol due to dyspnea. The patient's maximum heart rate was 187 beats/minute with a blood pressure of 211/135 millimeters of mercury (mmHg). His baseline ST segment abnormalities became more pronounced with exercise. Medical necessity for myocardial perfusion imaging with pharmacologic stress is at issue.

The health plan's determination is overturned. 

This service of myocardial perfusion imaging is medically necessary.
This patient, with a history of hypertension and atrial fibrillation, has complaints of exertional chest pain and dyspnea. An exercise treadmill test was non-diagnostic due to very poor exercise tolerance. Thus, some form of imaging with pharmacologic stress is required to rule out myocardial ischemia as a cause of his symptoms. The options include stress echocardiography (this involves infusion of dobutamine and would be a poor choice in this patient with atrial fibrillation and uncontrolled ventricular rates); Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) with pharmacologic stress, positron emission tomography (PET) perfusion imaging or magnetic resonance (MR) perfusion imaging. The latter two choices, while highly accurate, are less widely available.
Thus, the requested MPI is an appropriate choice in this instance and is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Vulvar Pain
Treatment: Pain Management (H-Wave Therapy)
The health plan denied the requested H-Wave Therapy. 
The health plan's determination is upheld.

The patient is a female with chronic/recurrent vulvitis, vestibulitis and vulvodynia. She has attempted estrogen, progesterone, and androgen therapy. Biopsy was negative. She utilized H Wave Therapy for treatment.

The health plan's determination regarding the proposed health service or treatment is upheld, in whole.

The proposed health service/treatment H-Wave therapy is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
H-WAVE type stimulators are experimental and investigational for diabetic peripheral neuropathy and for all other indications including any of the following indications because their effectiveness for healing, edema or pain has not been established.
H-Wave stimulation is a form of electrical stimulation that differs from other forms of electrical stimulation in terms of its waveform. The H-wave produces low frequency muscle stimulation and high frequency pain control. H-wave stimulation has been purported for use in pain control for conditions such as complex regional pain syndrome (reflex sympathetic dystrophy), muscle sprains, temporomandibular joint dysfunctions or treatment of diabetic neuropathy. However, H-wave stimulators have not been shown to be effective in reducing pain from causes other than chronic diabetic peripheral neuropathy, or in reducing edema or swelling. H-wave stimulation has not been demonstrated to be effective in treating chronic pain.
A systematic evidence review concluded that H-wave stimulation had a moderate to strong effects in relieving pain, reducing pain medication use and increasing functionality in patients with chronic soft tissue inflammation or neuropathic pain (Blum et al, 2008). A critique of this systematic evidence reviews by the Centre for Reviews and Dissemination (CRD, 2009) concluded that "it is not possible to determine whether the results of this review are reliable" given its significant methodologic limitations. In particular, very limited details of the included studies were given in the review; it was unclear which studies were randomized, no control interventions were detailed, and there were insufficient details on the outcome measures used. Although a validity assessment was performed, the results were not presented. "Given these omissions, it is difficult to assess either the internal or external validity of the results."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Vulvar Pain
Treatment: Pain Management (H-Wave Therapy)
The health plan denied the requested H-Wave Therapy. 
The health plan's determination is upheld.

The patient is a female with a history of vulvar pain, as well as vestibulitis, vulvodynia, and vulvitis. In the past, she has tried and failed to achieve pain relief with estrogen, progesterone, testosterone, dehydroepiandrosterone (DHEAS), and androgen therapy. She has been recommended treatment with H-wave therapy.

The health plan's determination regarding the proposed health service or treatment is upheld, in whole.

No, the proposed health service or treatment H-Wave therapy was not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There are no data from peer reviewed literature to support that use of this therapy is effective and/or safe in managing vulvar pain, it is not standard of care and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spondylosis without myelopathy or radiculopathy, lumbar region

Treatment: Physical therapy services for spondylosis without myelopathy or radiculopathy, lumbar region

The insurer denied coverage for physical therapy services for spondylosis without myelopathy or radiculopathy, lumbar region.

The denial is upheld.

This is a female patient with chronic medical problems including endometriosis, vertigo and spondylosis. The patient was seen by her physician for neck, shoulder and back pain complaints. Physical therapy was recommended and initiated. Currently under review is the medical necessity of physical therapy services for spondylosis without myelopathy or radiculopathy, lumbar region.

The clinical notes made available for review do not support medical necessity for the services requested. The clinical records consist of only 2 physician office visit notes, as well as a cervical spine magnetic resonance imaging (MRI) scan report. Based on the patient's letter, she received prior physical therapy and the effect on her pain would be relevant to any determination of the medical necessity for further therapy.  

Based on the limited clinical information made available for review, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the data provided for review do not support coverage for physical therapy services.

The medical necessity for physical therapy services for spondylosis without myelopathy or radiculopathy, lumbar region is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 diabetes mellitus

Treatment: K0553: supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service

The insurer denied coverage for K0553: supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.

The denial is upheld. 

This is a male patient with a medical history of type 2 diabetes, morbid obesity, and depression. He has benefited from continuous glucose monitor (CGM) real time data for dietary, lifestyle adjustments to improve and control his diabetes. The patient is treated with metformin hydrochloride (HCL) extended-release (ER) 500 milligrams (mg) twice a day and he does not use insulin. The patient's provider asked for coverage for a CGM device.

As per Young et al. (2017) open-label randomized trial, "[self-monitoring of blood glucose (SMBG)] is generally unnecessary in patients who are treated with diet alone or who take oral or injectable agents that do not cause hypoglycemia. SMBG is less effective in improving glycemic control in patients with type 2 diabetes not receiving insulin."

As per Kudva et al. (2018), "large randomized controlled trials demonstrated that use of the FreeStyle Libre system resulted in significant reductions in hypoglycemia, increased time in target range, reduced glycemic variability, and greater patient satisfaction compared with fingerstick monitoring [6, 7]. These benefits were seen in well-controlled type 1 diabetes (T1D) [6] as well as suboptimally controlled type 2 diabetes (T2D) treated with intensive insulin therapy [7]. Studies also showed high device utilization, suggesting that the FreeStyle Libre system may enhance patient engagement [6, 7]. Smaller observational and prospective studies have also shown improvements in both A1c and a reduction in hypoglycemic events [810]." 

Janapala et al. (2019)'s systemic review with meta-analysis further supports that while the benefits of continuous glucose monitoring in patients with  type 1 diabetes mellitus (T1DM) is well establish, it is less so for type 2 diabetes mellitus (T2DM). 

Based on the review of the documentation submitted and literature, and from the perspective of Endocrinologist Diabetes & Metabolism/Internal Medicine, the patient was placed on metformin for treatment of type 2 diabetes mellitus (T2DM) which is appropriate but the prescription of a continuous ambulatory CGM is not medically necessary since metformin does not carry a high risk of hypoglycemia and the patient is not on multiple daily insulin injections. The patient has no disability such as poor vision or tremors which would preclude the usage of regular glucose monitors over the CGM device. 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 K0553: supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is overturned. 

This is a female patient with a history of asthma, morbid obesity, hypertension and osteoarthritis. The patient was admitted to the hospital for an elective right total knee replacement. The patient's post-surgical course was non-complicated. The patient received physical therapy services and post-operative medications. The patient was discharged to a skilled nursing facility. 

Based on the review of the medical record and literature, the records demonstrate factors to substantiate this patient's inpatient admission and length of stay. The patient has underlying problems which support the inpatient level of care and treatments provided. The patient received anesthesia of almost 4 hours, which contributes to delays in this patient's mobilization. The patient has a body mass index (BMI) of 43 and previous total knee replacement on the left-side. Given these conditions, the patient would be expected to have difficulty with post-operative mobilization. The patient would have difficulty arising and move without assistance. The patient was at high-risk for a fall, and it was important that this patient reached full rehabilitative potential prior to transferring to a skilled nursing facility. The patient had difficulty getting out of bed and inability to walk more than 10 feet. There was a reported episode of dizziness and the need for the patient to sit down. Gradual progress was made where walking was able to be increased to 50 feet. The patient's physical therapy progress gradually improved. The patient's admission and length of stay were warranted by her underlying comorbidity and clinical course.

The full hospital admission is considered medically necessary for this patient.

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

The carrier's denial of coverage for the full hospital admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: OncotypeDx Genomic Prostate Score (GPS).

The insurer denied the OncotypeDx Genomic Prostate Score (GPS). The denial is upheld. 

The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed. The biopsy specimen was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 1 of 12 cores. No core had more than 50% involvement.  The clinical stage was T1c (nonpalpable prostate cancer diagnosed by needle biopsy). The PSA (prostate-specific antigen) was 4.2.

No, the OncotypeDx (GPS) was not medically necessary.

Per AUA (American Urological Association) Guidelines, "Guideline Statement 32 Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)."

Per AUA (American Urological Association) Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"

Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test.  The NCCN (National Comprehensive Cancer Network) Guidelines note that, "Their clinical utility awaits evaluation by prospective, randomized clinical trials, which are unlikely to be done."

The NCCN Guidelines state that, "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear...Any of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."

Therefore, given the above, the OncotypeDx (GPS) was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontically involved teeth
Treatment: Extraction of teeth #s 9 and 10 and the 5-unit bridge of teeth #s 7, 8, 9, 10 and 11
The insurer denied the Extraction of teeth #s 9 and 10 and the 5-unit bridge of teeth #s 7, 8, 9, 10 and 11.
The denial is upheld. 

The patient is a female. The patient has periodontally involved teeth number (#) 9 & #10. The provider plans to remove these and place a bridge from #7 to #11. The health plan denied this in favor of a partial denture, which the health plan considers to be an adequate and appropriate procedure.

No, the extraction of teeth #s 9 and 10 and the 5-unit bridge of teeth #s 7, 8, 9, 10 and 11 are not medically necessary.

The treatment of partial edentulism through fixed or partial removable prostheses comprises a series of stages that consists of complete charting of caries, existing restorations, periodontal tissues, to include pocket probing and mobility, and general bone levels. The specific and nonspecific mouth preparation will cover any therapy required to bring the mouth to optimum health and to modify tissue in such a manner as to make the final prosthesis ideal. 

The provider states that all abutment teeth are sound, but the radiographs are the only documentation. These reveal periodontal disease on all the abutment teeth, particularly #11, which has more than 50% bone loss. In addition, the radiographs show multiple other teeth with severe periodontal disease that are non-salvageable. Elimination of the existing dental disease will need to be performed prior to the evaluation of a bridge in the #7 - #11 area.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower extremity swelling, fever, drainage.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is overturned. 

The patient is a female with history of scoliosis and status post (s/p) T2-L4 (thoracic spine 2 to lumbar spine 4) fusion with osteotomies.  The patient underwent flaps and complex closure of open wound.  She was progressing and ambulating well, but developed lower extremity swelling and presented to the emergency room for increasing back pain, wound drainage, fever and leg swelling with 20 pound weight gain.  She was tachycardic to 127. Computed tomography (CT) of the chest was done and ruled out pulmonary embolism and the patient was admitted for additional work-up.  Ultrasound (u/s) was negative and she had cardiac and medical work-up.  The patient was taken off gabapentin and her swelling improved.  She was started on intravenous (IV) antibiotics and IV morphine for pain. The patient was stabilized, fever resolved, and plastic surgery completed a bedside wound closure.  

Yes, the inpatient hospital admission was necessary.  

The patient had multiple medical issues including fever and tachycardia, and a sepsis workup was appropriate given the draining wound.  In addition, the patient had lower extremity swelling and deep venous thrombosis and other potential cardiac causes had to be ruled out. It would not have been proper care to send this patient home.  

The best interest of the patient was the inpatient stay and the medical work-up that was supplied to the patient.  There were many issues that needed to be addressed and would have been difficult to coordinate as an outpatient.  Advanced imaging was done with CT scan,  Furthermore, the patient required IV pain medications and it was prudent to start the patient on IV antibiotics with a draining wound and fever.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lower extremity cellulitis.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a male patient with past medical history significant for hypertension, hyperlipidemia, diabetes mellitus, obesity, and status post great toe amputation who presented to the Emergency Department (ED) with complaints of dizziness and right foot pain. The patient's vital signs on ED presentation included: Temperature 99, Blood Pressure 137/69, Pulse 99, Respiratory Rate 18, Oxygen (O2) Saturation 98% on Room Air. The patient's laboratory results included the following: white blood cell count (WBC) 16.4, hemoglobin 12.9, hematocrit 39.6, creatinine 0.94, glucose 167, B-type natriuretic peptide (BNP) 1168, and troponin 0.205. The patient was started empirically on intravenous (IV) antibiotics (i.e., Unasyn) for right lower extremity cellulitis. The patient underwent a cardiac work-up for elevated troponins. The patient remained afebrile, clinically, and hemodynamically stable. The patient was discharged to continue oral antibiotics as an outpatient. 

According to documentation, the patient presented with right lower extremity cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, and laboratory results showed an elevated WBC count. The patient had a localized cellulitis with no evidence of a disseminated infection; no surgical intervention was required. Based on above findings, the patient met criteria for observation level of care. The patient did not meet criteria for acute hospital admission. Based on the review of the medical record and literature, the inpatient hospital admission was not medically necessary for this patient.

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

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.