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

Diagnosis: Low back pain.
Issue under review: MRI (magnetic resonance imaging).
The insurer denied the MRI (magnetic resonance imaging).  The denial is upheld. 

No, the MRI performed was not medically necessary.

The patient is a female. 

In a letter from the patient's provider, it indicates the patient was seen by neuromuscular specialist for neuropathic pain.  She reportedly has been to see other specialists including Hematology and Internal Medicine and was referred to undergo MRI of lumbar spine for low back pain with radicular symptoms.  She had previously been recommended by the previous colleague, who stated that an MRI of the spine was considered medically necessary.

A note encounter from the patient's provider, Hematology indicated ongoing treatment for monoclonal gammopathy, neuropathy, and anemia.  Reportedly has probable peripheral neuropathy, onset five months, worsening.  She is experiencing paresthesias, more prominent on the left versus the right.  Physical exam indicated gait was normal.  She had intact sensation to touch.  Reflexes were normal.  She was assessed as having gammopathy, monoclonal, nonspecific; neuropathy, peripheral; and anemia and was recommended for ongoing care.

Evaluation patient's provider assessed the patient has superficial sensory loss suggestive of a small-fiber peripheral neuropathy.  Neurologic exam was normal.  Noted back pain with radicular features.  She was recommended for MRI of the lumbar spine and EMG.

There is a report recommending follow-up MRI in six months.

Note from nurse practitioner assessed the patient had developed numbness and tingling of her feet.  Complains of painful burning interfering with her ability to sleep.  Complains of left hip pain.  Having pain in greater trochanter.  She has worsening numbness and tingling, now involving her head.  Neurologically, was alert and oriented to person, place, and time.  DTRs (deep tendon reflexes) were present in knees and ankles.  She reported ongoing treatment of gammopathy of monoclonal type, neuropathy and anemia.  She reports increased difficulty with balance and gait.  Her gait was slow with limping gait due to left hip pain and was recommended for follow-up treatment.

A Neurologic examination noted the patient had normal gait and balance. Pinprick and vibration sense were reduced in lower extremities.

MRI of lumbar spine is not supported as medically necessary based on the medical records provided for review.  The available medical records reflect the patient having complaints of back pain but do not otherwise relate ongoing symptoms or conditions or any demonstration of physical exam findings consistent with radiculopathy or other findings consistent with nerve impingement at the lumbar spine level or other lumbar spine pathology.  The available medical records do not indicate suspicion of either malignancy or infection.  As such, MRI of lumbar spine is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma Exacerbation With Lactic Acidosis.
Issue under review: Inpatient admission. 
The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male with history of asthma.  He presented to emergency room with wheezing and was found to have asthma exacerbation due to upper respiratory tract infection. 

In the ER, the patient received frequent nebulizations, IV steroids and IV antibiotics.  The patient was admitted to acute in hospital level of care for continued treatment with IV steroids, nebulizations, and IV antibiotics.

Patient has moderate asthma exacerbation and symptoms did not improve with emergency room care.  The patient was admitted for asthma exacerbation.  The patient continued to have wheezing and chest tightness, but he was able to speak in full sentences.  At the time of admission, the patient's chest tightness had resolved.  The patient's condition had improved with emergency room care.  The patient was able to tolerate oral diet and was able to ambulate. 

The acute inpatient level of care is not medically necessary.  The patient could have been safely and effectively be treated in observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/Circulatory Problems
Treatment:  Inpatient Hospital

The patient is a male with a history of abdominal aortic aneurysm.  He presented to the emergency department complaining of upper mid-chest pain and dyspnea.  His blood pressure was 167/100 millimeters of mercury (mmHg) with a heart rate of 89 beats/minute.  His respiratory rate was 17/minute with a room air oxygen saturation of 97%.  His cardiac and respiratory physical exams were normal.  His electrocardiogram showed sinus rhythm with premature ventricular beats.  The QT interval was borderline prolonged.  There were no acute ischemic changes.  The patient's serum troponin level was normal.  He was treated with aspirin and admitted to the hospital.  The following day the patient denied chest pain.  He was started on metoprolol.  An echocardiogram showed a normal left ventricular ejection fraction.  There was impaired relaxation.  There was trace mitral, tricuspid and aortic regurgitation and mild pulmonic regurgitation.  The following day cardiac catheterization was performed and showed nonobstructive disease.  The procedure was uncomplicated.  Discharge was delayed to allow time for arrangements for the patient to be sent to a shelter.  Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

An inpatient admission was not medically necessary.  This patient presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS).  Accordingly, monitoring until ACS could be ruled out was a reasonable approach.  However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes.  There is no indication in the records provided that other potentially life-threatening diagnoses were thought to be likely.  He 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.  Moreover, it does not appear as if there was a medical reason for the patient's continued hospitalization after cardiac catheterization showed nonobstructive disease.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes
Issue under review: Formulary exception for Janumet

Determination:
The health plan should cover the Formulary exception for Janumet.

The patient is an adult female with type II diabetes. She has tried and failed Jentadueto. She has also tried and failed metformin alone. She has done well on Janumet in the past. 

This patient has tried and failed Jentadueto due to hyperglycemia. Jentadueto XR is expected to have the same efficacy as Jentadueto, and therefore is not an appropriate alternative for this patient who has tried and failed Jentadueto. Hyperglycemia can cause retinopathy, neuropathy, and nephropathy. This patient has been successfully treated on Janumet in the past. Therefore, yes, the health plan should cover the proposed Janumet.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

The patient is a woman who was brought to emergency department (ED) by Emergency Medical Services (EMS) for evaluation of syncope, which was witnessed. The patient was at the hairdresser and she lost consciousness for 15 seconds. There was no fall or trauma. The additional history was important for recent onset of watery diarrhea (3 episodes on the day of presentation) and dizziness, lethargy and generalized weakness prior to syncope. The patient also had recently diagnosed congestive heart failure and hypertension. She was scheduled for cardiac catheterization as an outpatient. The patient also has history of rheumatoid arthritis. She was admitted to the hospital. The inpatient stay is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient did not have indications for an inpatient admission. She presented with syncope and very low blood pressure after taking diuretics and having diarrhea, just preceding this episode. The patient clearly was fluid depleted and hypotensive with low blood pressure which caused syncope. She responded to IV hydration very quickly and her symptoms resolved. Her BP went up, her lactic acid improved and her creatinine improved. She did not have evidence of severe organ damage from her hypotension. Her troponin was normal, and her urinalysis was unremarkable. The patient did not have evidence of ongoing sepsis. She only received IV hydration, and there were no indications for antibiotics.

The patient was on telemetry while in the hospital. She was in sinus rhythm, without significant arrhythmia, an only occasional premature ventricular contraction (PVC). The patient also had one episode of non-sustained ventricular tachycardia and she was asymptomatic with it.

From cardiac standpoint, the patient had low left ventricular ejection fraction (LVEF), however, that information was not new. The patient underwent cardiac catheterization while she was in the hospital. The procedure previously was planned as outpatient. Considering her normal troponin and unremarkable ECG, the procedure could have been done as outpatient. Her oral medications were adjusted, and she remained stable.
The level of care provided for this patient, and her condition did not meet inpatient admission criteria. A lower level of care would be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional
Inpatient Hospital

The patient is a male with past medical history of asthma, tobacco smoking, and alcohol dependence, who presented to the emergency department with increased thirst and urination.
On presentation, the patient was afebrile with blood pressure (BP) 129/71, heart rate 90, and respiratory rate 18, with an oxygen saturation of 96% on room air.
Exam otherwise noted him to have dry mucus membranes. Labs showed white blood cell count 6.7, hemoglobin 14, platelets 208, sodium 130, potassium 4.3, bicarbonate 23, blood urea nitrogen (BUN) 9, creatinine 1.04, normal anion gap, magnesium of 1.5, liver function tests that were unremarkable, troponin that was negative, lactic acid 0.8, and arterial blood gas with pH 7.39/partial pressure of carbon monoxide (pCO) 240/ partial pressure of oxygen (pO2) 74 on room air. Urine drug screen was positive for marijuana and urinalysis showed trace ketones without evidence of infection. Electrocardiogram (EKG) showed no acute ischemia. Chest x-ray showed no acute process. The patient was given intravenous (IV) insulin and IV fluids in the emergency department with repeat blood glucose measured at 294. He was subsequently brought into the hospital with concern for newly diagnosed diabetes and plan for IV fluids, starting Lantus, short-acting insulin, and metformin, checking HgBA1c, and consulting endocrinology.
The patient remained hemodynamically stable. His symptoms improved. HgBA1c resulted at greater than (>)15.5% and creatinine repeated was 0.64. He was seen by endocrinology with assessment that he had newly diagnosed diabetes with plan to continue short and long-acting subcutaneous insulin and to have the patient follow up in outpatient endocrinology clinic. The patient was subsequently discharged. The issue in question is whether care at the inpatient level of care was medically necessary.

The health plan's determination is upheld.

Inpatient stay was not medically necessary. As previously noted, this patient presented with new onset diabetes with blood glucose >500, pseudohyponatremia in the setting of hyperglycemia, mild acute kidney injury with increased in creatinine from 0.64 to 1.04, magnesium of 1.5, and otherwise unremarkable labs. In the absence of diabetic ketoacidosis, altered mental status/evidence of non-ketotic hyperosmolar coma, or other process requiring inpatient care or anticipated to prolong his hyperglycemia and lead to complications (infection , acute coronary syndrome, etc.), it is not evident why this patient was high risk for morbidity/mortality, why prolonged length of stay would have been anticipated, and why he was not safe to care for at a lower level of care status. Ultimately, he also stayed only one midnight. Treatment at a lower level of care status was appropriate and care at the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Care

This is a patient with a past medical history of Parkinson's disease and Lewy body dementia who had an assessment for personal care aide (PCA) services and was assigned 4 hours/day, 7 days/week to total 28 hours/week. The patient was noted to be total assistance for meal preparation, ordinary housework, managing finances and shopping. The patient was assessed at maximal assistance for phone use and managing medications. Extensive assistance was assessed for stairs and bathing. The patient was assessed at limited assistance for eating, transfer toilet and dressing upper/lower extremity. For walking and locomotion, the patient was assessed at a supervision level of care and independent for bed mobility, toilet use and personal hygiene. There was a request for increased PCA services to 8 hours/day, 7 days/week to total 56 hours per week. The health plan denied this request. The patient's neurologist wrote a letter noting that the patient had worsening of her Parkinson's and dementia and because of her dementia she was often forgetting her Parkinson's medication which caused her to have more difficulty with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and caused her to be at an increased risk of falls. The provider recommended an increase in PCA services. At issue is the medical necessity of an increase in Personal Care Aide Level 2 Services: 8 Hours Per Day - 7 Days per Week - for a Total of 56 Hours per Week 
The health plan's determination is overturned. The requested services are medically necessary. The patient has the diagnosis of Parkinson's disease and Lewy body dementia. The patient requires medication twice daily to control her Parkinson's symptoms. When her Parkinson's symptoms are not in control she has more difficulty with ADLs and IADLs. Because of the patient's dementia, she often forgets her medications. Although the patient may have limited assistance needs for some of her ADLs and IADLs, she patient needs to take her medication twice daily and requires maximal assistance with medication management, which would not fall in the 4 hour window in which the patient has PCA services. Also, the patient was noted to be total assistance for meal preparation, ordinary housework, managing finances and shopping. The patient was assessed at maximal assistance for phone use. Extensive assistance was assessed for stairs and bathing. The patient was assessed at limited assistance for eating, transfer toilet and dressing upper/lower extremity. For walking and locomotion, the patient was assessed at a supervision level of care and independent for bed mobility, toilet use and personal hygiene.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory System
Treatment:  Inpatient Hospital

The patient is a female with a past medical history significant for asthma, chronic obstructive pulmonary disease (COPD), ongoing tobacco use, depression, anxiety, and chronic back pain who presented to the hospital with acute onset of fever, chills, and rigors.

Her symptoms started three days before the day of admission as cough with purulent yellowish sputum, generalized body aches, and flu-like symptoms.  On the day of admission, the patient noticed a fever.

The health plan's determination is overturned.  The inpatient stay was medically necessary.  Even though the severity of community-acquired pneumonia did not rise to the level of inpatient care, the pneumonia was associated with sepsis syndrome, which is a very serious condition with high mortality rates if it remained inadequately treated.  The review of the medical records demonstrated that there was a high probability that the patient had sepsis syndrome requiring admission at the acute inpatient level of care. 
The patient presented to the hospital with community-acquired pneumonia, which was associated with sepsis syndrome that was suspected based on the positive SIRS criteria in addition to multiple episodes of hypotension as well as elevated lactic acid level.  This patient appropriately received treatment with intravenous fluids, intravenous antibiotics, intravenous corticosteroids.  The severity of the patient's condition and the complexity of the services provided completely justified admission at the acute inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld


Reviewer #3

Diagnosis: Rosacea

Treatment: Intense Pulse Light Treatment (IPL)

The insurer is denied coverage for Intense Pulse Light Treatment (IPL).

The denial is upheld. 

This is a male patient with rosacea. The patient has been treated with metronidazole, as well as Azelex and Retin-A. This is a review regarding coverage for IPL. The patient has been previously treated with Intense Pulse Light treatment (IPL). 

The medical literature, as well as guidelines by the National Rosacea Society, supports the use of IPL in improving the health outcome for patients with rosacea. In a small study by Kim et al. (2018). IPL was compared to pulsed dye laser [PDL] in patients with rosacea. "Six patients with rosacea were enrolled to a randomized, single-blinded, placebo-controlled, spilt-face trial. Subjects presented for four treatments with a submillisecond IPL (Ellipse) to one half of the face and PDL (Candela) to the other half. Each treatment consisted of 4 sessions at 2 week intervals and followed up until 2 weeks after the last treatment. Efficacy was assessed by erythema, melanin index, physician's subjective evaluation, and patient's satisfaction. Submillisecond IPL was effective in the treatment of rosacea."

There is no clear documentation of the patient's activities of daily living (ADLs) affected by the rosacea with burning, stinging, pain or how other treatments have fared in managing the symptoms. The re cords do not clearly indicate how the patient is a good candidate for treatment.

Topical preparations such as Mirvaso, oral tetracyclines, topical ivermectin, would be considered conventional first-line options. There are no head-to-head studies showing that IPL would be safer or more effective than these conventional therapies. Therefore, the requested IPL treatment is not considered to be more beneficial than any standard treatment for this patient.

The carrier's denial of Intense Pulse Light Treatment (IPL); CPT code 17108 ([destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq. centimeters (cm)], for date of service should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2

Diagnosis: Rosacea

Treatment: Intense Pulse Light Treatment (IPL)

The insurer is denied coverage for Intense Pulse Light Treatment (IPL).

The denial is reversed. 

The patient is a male who has a diagnosis of rosacea that is described as burning and stinging in handwritten clinical notes. The condition was treated with Intense Pulse Light treatment. The patient tried and failed azelaic acid, metronidazole, and Retin A. The insurer's denial indicated that the requested IPL treatment failed to meet the criteria of peer reviewed medical literature as being effective for the patient's diagnosis. 

Intense Pulse Light (IPL) is supported by peer reviewed literature for treatment for rosacea for the symptoms of pain, burning, and stinging. Based on the described symptoms in the notes, the patient is a good candidate for IPL treatment. The IPL is a good treatment for this patient who has failed topical treatments.IPL is more beneficial for the patient than any standard treatment due to his symptoms. Furthermore, the patient tried and failed azelaic acid, metronidazole, and Retin A. In this case, IPL is more beneficial than other standard treatments for the patient. 

The carrier's denial of Intense Pulse Light Treatment (IPL); CPT code 17108 ([destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq. centimeters (cm)], for date of service should be reversed.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1

Diagnosis: Rosacea

Treatment: Intense Pulse Light Treatment (IPL)

The insurer is denied coverage for Intense Pulse Light Treatment (IPL). 

The denial is upheld. 

The patient is a male with a history of rosacea. He has symptoms of burning, stinging, deep pain and erythema. Per the patient's appeal letter, he writes that his Dermatologist, successfully treated his rosacea in the past with Intense Pulse Light (IPL) treatment. His first treatment was over a decade ago. He notes that he has tried and failed Azelex, Metronidazole and Retin-A.

In the appeal letter the patient writes that two of his prior insurance companies recognized and authorized IPL treatments. He notes that IPL for Rosacea has been shown to be safe and effective. His symptoms (pain, burning, stinging and pounding) are not cosmetic. Handwritten notes were included for review.  The patient received Intense Pulse Light (IPL) treatment.

Intense pulse light has been found to be safe and effective for the treatment of rosacea resistant to conservative therapy. Therefore, the scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. Intense Pulse Light Treatment is Food and Drug Administration (FDA) approved. 

The patient has a history of rosacea. He has symptoms of burning, stinging, deep pain and erythema. He has tried and failed Azelex, Metronidazole and Retin-A. However, there are available standard treatments the patient has not tried and failed. Therefore, the patient is not a good candidate for Intense Pulse Light Treatment. 

There are available standard treatments the patient has not tried and failed. Oral tetracyclines, topical ivermectin, and brimonidine are considered first line conventional therapy. Therefore, the Intense Pulse Light Treatment is not the best available treatment for this patient at this time.

The requested service, Intense Pulse Light Treatment is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of Intense Pulse Light Treatment (IPL); CPT code 17108 ([destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq. centimeters (cm)], for date of service should be upheld.