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

Depression
Mental Health: Inpatient

The patient is a male admitted to the MH RTC level of care.  The patient is diagnosed with MDD, recurrent episode, moderate, GAD, Cannabis use disorder, moderate, in a controlled environment.  The patient was self referred due to depression, anxiety and cannabis use disorder.  Treatment goals to work on coping skills for depression, improve family communication, gain insight into substance use.  The program is noted to be a weekly routine split between residential and a wilderness adventure approach.  At the time of admission, the patient was noted to have severe depression, mild to moderate anxiety and moderate to high family dysfunction. The patient was using cannabis.  The patient had pressured in school and was discharged with depression.  The patient confessed to using cannabis. Zoloft was started by his PCP, which he later stopped on his own. The patient started to see a therapist.  The patient started to smoke cannabis daily and vaping.  The patient was leaving school without permission, serving detentions and failing classes.  The patient had 2 episodes of passive suicidal ideation. The patient later in the year was caught by police smoking pot with friends and participated in a 15 hour group drug and alcohol awareness program.  He had been referred to a psychiatrist, but refused to go. The patient has no previous hospitalizations.

The health plan's determination is upheld. MH residential treatment was not medically necessary for the patient. The patient was not suicidal, homicidal, psychotic, self injurious or physically aggressive within the 2 weeks prior to admission or during the patient's stay.  The patient was medically stable.  The patient was not at risk for severe withdrawal. There was no indication for around the clock monitoring.  Treatment could have been addressed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ankle fracture

Treatment: Inpatient hospital services 

The insurer denied coverage for inpatient hospital services. The denial was upheld.

This patient is a female with several medical conditions who fell. She was found to have a left ankle fracture. She was admitted to hospital for open reduction internal fixation of the ankle. Her post-surgical course was non complicated receiving consultations from physical therapist and pain management specialist.  She was found "not to be safe to return home as she lived alone in a 2 story walkup.'" She was discharged to a nursing home. 

The medical record demonstrates surgical management was not complex or extensive. She sustained an isolated low energy type injury to one body part. The duration of the procedure was approximately one hour with regional anesthesia provided. There was limited blood loss. The procedure was performed solely to the lateral aspect of ankle with no medial/syndesmotic fixation required. Her physician applied a plate and screws to the distal fibula. The post-surgical course was without problem. There was no evidence of inability to tolerate oral pain medication. There were no associated medical conditions to require intense management. She was evaluated by Physical Therapy on post-operative day 1. Social service records denote Discharge Planning for Sub acute facility. These findings do not substantiate necessity for the inpatient admission. The "Safe Discharge" issues could have been completed at Observation type status. There were no extenuating circumstances to substantiate the admission and length of stay.

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

Based on the above, the medical necessity for the inpatient hospital services is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hypertension, hyperlipidemia and type II diabetes. Per an office note, she had tried rosuvastatin (Crestor), with discontinuation due to side effect of nausea. Her medications included Praluent. (It is not clear if she was taking this medication, however, as per the appeal letters the medication was denied coverage). She had a total cholesterol of 268, high density lipoprotein (HDL) of 49 and low density lipoprotein (LDL) of 192. The health plan's determination is upheld. Adequate trials of statin therapy are not documented.

The patient has hyperlipidemia, with an LDL of 192 and requires treatment. Per the documentation provided, she had tried one statin - rosuvastatin, with a side effect of nausea. A side effect with one statin does not indicate an intolerance to all statins. As statins are first -line treatment for hyperlipidemia per current American College of Cardiology (ACC)/American Heart Association (AHA) guidelines and use of Praluent (alirocumab) at this point is not indicated. Trials of statin therapy are indicated prior to consideration of a PCSK9 inhibitor.
Appeal type: Medical necessity
Decision: Upheld

Hernia
Physical Therapy

The patient is a male status post left sports hernia repair. The date of hernia repair is not clear and there are no physician records other than a physical therapy prescription provided for this review. The date of "injury" is listed in the physical therapy (PT) notes but this cannot be assumed to mean date of surgery. The patient was prescribed PT. The medical necessity for PT visits is under review.

The health plan's determination is upheld. The requested physical therapy services are not medically necessary. Based on review of the records provided, the therapeutic exercises provided in PT were of low complexity/simplistic and thus could have been performed by the patient on his own. There is no rationale provided on the part of the treating PT (physical therapist) as to why supervised or higher level of therapeutic exercise needed to be administered. There is no support for medical necessity in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Uterine Fibroids
Treatment:  Radiology Services

The patient is a female with uterine fibroids causing symptoms.  These include menorrhagia and bloating with abdominal distention and constipation.  She also has history of urinary (bladder) frequency. No dyspareunia.
The request was for a uterine artery embolization (UAE) to treat her symptomatic enlarged fibroid uterus.  Previous ultrasound shows a diagnosis of fibroids.  Imaging, a pelvic magnetic resonance imaging (MRI), notes a very large fibroid and more enlarged uterus.  Anemia is not documented.
She also has had some previous treatment including supplements and change in diet.  Watchful waiting conservative therapy approach used for 2 years.  Analgesics are not warranted as she did not have dysmenorrhea.  Hormone treatment is not necessary as an alternative therapy.
An endometrial biopsy could be considered.  However, a Pap smear is of no new clinical value, as cervical cancer has no relationship to fibroids.  Irritable bowel, anxiety and fatigue noted.  Past medical history includes other documented findings.
The current treatment plan was the UAE, already performed.
The subject under review is the medical necessity of the procedure.

The health plan's determination is overturned.

The requested treatment of uterine artery embolization is medically necessary for this patient.
This patient will expect a significant reduction in the size of the dominant fibroid and an overall shrinkage in the size and volume of her uterus within several months after the procedure.
This will in turn decrease her symptoms of abdominal distention, bloating and urinary frequency.
Other advantages and benefits include a short recovery time after the procedure, low overall risk, use of a minimally invasive image guided therapy with few side effects anticipated, and little blood loss.  No general anesthesia and no surgical incision are required.  Less future regrowth of fibroids expected in the future.
Fibroids are a significant uterine problem and caused multiple symptoms in this patient. UAE has been a reasonable treatment choice for years and was employed appropriately.  The patient had waited after diagnosis for two years doing conservative management (watchful waiting) with only worsening of symptoms and enlargement of her fibroid uterus.
Uterine fibroids when treated by UAE is state of the art therapy and a reasonable choice for this patient.  Hysterectomy should not be a young patient's choice.  The UAE was the best therapeutic choice.
Appeal type: Medical necessity
Decision: Upheld

Breathing Problem
Inpatient Hospital

The patient is a female with prior history of chronic obstructive pulmonary disease (COPD) of unknown severity with home use of oxygen at 2 L as needed, sarcoidosis, and diabetes mellitus (DM) who presented to the emergency department (ED) with worsening shortness of breath associated with cough. Her symptoms worsened over a week after inhaling bus fumes and fluctuating temperature with weather changes. On the morning of presentation, she woke up with acute worsening of symptoms of her symptoms of shortness of breath associated with cough. She presented to the ED. Her vitals were normal except oxygen saturation of 89% on room air which came up to 92-94% range with her chronic oxygen requirements. She was noted to be diffusely wheezing but otherwise appeared non toxic. She was on a tapering dose of prednisone at 5 milligrams (mg) by mouth (PO) daily at home as she was preparing for an upcoming elective umbilical hernia repair surgery. Her CXR (chest x-ray) revealed bibasilar atelectasis.

The health plan's determination is upheld. The inpatient admission was not medically necessary. Based on the patient's presentation, a lower level of care would have been appropriate with no worsening of oxygen, increased frequency of bronchodilators needed, or hypercarbia. There were no other active comorbid conditions at the time of admission or alteration in mental status and severe change in vital signs which necessitated an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of right knee

Treatment: Monovisc

The insurer denied coverage for Monovisc. The denial was upheld.

This patient is a female with osteoarthritis of the right knee.  She was evaluated by an orthopedic surgeon.  Her pain increases with walking.  She has tried ice, rest, and over the counter (OTC) medications. The physical examination was significant for patellofemoral tenderness, crepitus, and medial joint line tenderness. An x-ray report revealed marked degenerative arthritis medially.  Her physician provided a cortisone injection. Authorization was also requested for Monovisc.  The denial was based upon this medication not being on the preferred list. 

The medical record demonstrates that the patient has osteoarthritis and has failed conservative treatment.  There is documentation that physical therapy, injections, and medications have been tried and failed. The criteria for use of viscosupplementation have been established. However, there is no evidence of contraindications or inability to tolerate formulary viscosupplementation.  There is no evidence of reactions, problems, or medical contraindications for formulary viscosupplementation.  There is insufficient evidence in the medical record to support the use of Monovisc vs. formulary sodium hyaluronate alternatives. There were no extenuating circumstances reported to support the use of Monovisc. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Monovisc is not medically necessary.

Based on the above, the medical necessity for Monovisc is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital stay

The patient has a history of coronary artery disease, aortic valve replacement, aortic root-left ventricle fistula, diabetes, hypertension and morbid obesity. He presented to the emergency department complaining of one week of intermittent sharp, stabbing chest pain with radiation to back, neck and left arm and associated headache, palpitations, dizziness and exertional dyspnea. Patient was treated with intravenous morphine and metoprolol with resolution of pain. Patient was admitted to the hospital to rule out acute coronary syndrome. Repeat troponin levels were normal. Coronary computed tomography angiography showed no obstructive disease. The health plan's determination of medical necessity is upheld in whole. This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for ACS. Observation in the hospital until ACS could be ruled out was reasonable and prudent. On the other hand, patient was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Patient 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. This approach has been shown to be both safe and cost-effective and is in accordance with the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Joint Fracture/Break
Skilled Nursing Facility

The patient is a male with medical history significant for diagnosis of chronic obstructive pulmonary disease (COPD) and left perihilar squamous cell carcinoma (SCC). He suffered a right tibia/fibula fracture following a fall and underwent open reduction internal fixation (ORIF). Hospital course was complicated by hypoxia found to be secondary to collapsed left lung requiring radiation treatment. Shortness of breath improved and he was discharged to skilled nursing facility for rehabilitation.
Under review is the continued stay in the Skilled Nursing Facility.

The health plan's determination is upheld. The continued stay in the Skilled Nursing Facility was not medically necessary. This patient is medically stable, not on any antibiotics, does not have any reported skilled nursing needs and is at a SBA/Supervision level for mobility. He is ready to be discharged to a lower level of care. Furthermore, while the patient's skilled nursing facility stay was complicated by pneumonia, uncontrolled anxiety, urinary tract infection, allergic rhinitis and insomnia, the provider addressed each of these issues. Furthermore, the provider noted that urinary tract infection had resolved, and she stated that patient's anxiety had improved. Also, review of Resident Profile, did not list any antibiotics. Therefore, there was no documentation that the patient required continued skilled nursing, he was at a supervision to stand by assist (SBA) level for mobility and was ready to be discharged to a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2 

This case involves a female who has a past medical history to include pelvic congestion syndrome.  The submitted documentation detail the patient does have long-standing cyclical pelvic pain with pressure correlating with her menses, pain during/after sexual intercourse, and pelvic pain which worsens upon standing.  There is no other demonstrable anatomic condition to produce these symptoms.  The patient has been seen by gynecology and has undergone a rigorous clinical evaluation.  The findings are consistent with pelvic congestion syndrome which includes recurrent varicose veins to lower extremities and vulvar varices.  A CT venogram also was performed showing large ovarian and pelvic veins.  The patient has undergone selective ovarian venography demonstrating enlarged ovarian veins as well as reflux and ovarian varices.  The documentation detailed the patient has been recommended to undergo bilateral gonadal vein embolization.

According to current literature ablation of pelvic venous incompetence is a relatively simple safe and efficacious technique and conventional catheter techniques were used typically under conscious sedation and plain commonly available occlusive agents.  The procedure has a shallow learning curve and complications associated with therapeutic embolization are well-defined, rare and easily managed percutaneously.  Additional guidelines indicate improved reporting with standardized diagnostic tools to include pain assessment and quality of life surveys as well as long-term result reporting with objective imaging and clinical parameters have increased acceptance of the procedure.  Given that the patient has classic clinical symptoms, as well as imaging evidence indicating pelvic congestion gonadal vein embolization would be appropriate.  The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.  The procedure does have final approval and the patient is noted to be a good candidate.  As such, the vein embolization for pelvic congestive syndrome is considered the best available treatment for this patient at this time.  Therefore, the requested service is likely to be more beneficial and the prior determination is reversed.

The carrier's denial of coverage for vein embolization for pelvic congestion syndrome should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome

Treatment: Vein embolization for pelvic congestion syndrome

 The insurer denied coverage for Vein embolization for pelvic congestion syndrome. The denial was reversed.

Reviewer #1:

This patient is a female currently diagnosed with pelvic congestion syndrome. The CTA of the abdomen and pelvis revealed markedly enlarged and engorged bilateral parametrial veins which appeared to be related to dilated and likely insufficient ovarian veins bilaterally. The procedure note revealed bilateral pelvic gonadal vein reflux. The patient had experienced long-standing cyclical pelvic pain and pressures that correlated with her menses, pain during and after sexual intercourse, pelvic pain worse upon standing.  The patient had no other demonstrable anatomic condition to produce the symptoms.  The patient did have physical findings that are commonly found in pelvic congestion syndrome including recurrent varicose veins in the lower extremities and vulvar varices.  Additionally, a CT venogram of the pelvis showed large ovarian and pelvic veins and an ultrasound of the pelvis was performed which demonstrated enlarged pelvic varicosities, more prominent on the left than the right supporting a diagnosis of pelvic congestion syndrome.  The patient had undergone selective ovarian venography that demonstrated enlarged ovarian veins, reflux and those pains and ovarian varices.  Selective iliac venography suggested no contribution from these veins.

According to the current peer-reviewed medical literature, pelvic congestion syndrome is defined as the presence of ovarian and pelvic varicose veins associated with chronic pelvic pain persisting for more than six months that increases with prolonged standing, coitus, and menstruation.  The records provided indicate the patient had been symptomatic for a significant amount of time. The patient had pain with menses, sexual intercourse and with standing.  The literature supports that embolization is the gold standard treatment of pelvic venous insufficiency or pelvic congestion syndrome, while being minimally invasive.  Given that the patient has had this condition for an extended period of time and the patient has pain that increases with menstruation, coitus and standing, the literature does support embolization in this clinical circumstance.  The scientific evidence and peer-reviewed literature does support a result of improvement in health outcome.  The vein embolization for pelvic congestion syndrome does have final approval from the appropriate regulatory bodies and the patient is a good candidate for vein embolization for pelvic congestion syndrome.  This is the best available treatment for the patient at this time.  Therefore, the requested vein embolization for pelvic congestion syndrome is likely to be more beneficial than any other standard treatment/procedure for the patient.  The prior determination is reversed.

The carrier's denial of coverage for vein embolization for pelvic congestion syndrome should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Abdominal pain
Inpatient Hospital

The patient is a female with a history of asthma, left leg weakness, and nephrolithiasis who presented with worsening of chronic abdominal pain, urinary retention, and bloody diarrhea. She was in her usual state of health until early in the morning of admission, when she began to have acute worsening of her baseline abdominal pain and she developed diarrhea. She had approximately 7 episodes of diarrhea and she noted specks of blood in the stool. She was also not able to urinate normally. She intermittently requires catheterization for urinary retention, and had been seen by urology in the past. She also noted that she had passed a stone 2 days prior to her presentation, but continued to have pain. She also had nausea. She presented to the emergency department because she had been unable to void for 24 hours since the abdominal pain had developed.

The health plan's determination is overturned. The inpatient hospital stay was medically necessary for this patient. This is a female with a complex medical history including a history of nephrolithiasis, who presented with abdominal pain and urinary retention. She also developed bloody diarrhea. At the time of presentation, she had been unable to void for 24 hours. She continued to have pain and diarrhea despite appropriate treatment with intravenous fluids and pain control in the emergency department setting. She was found to have urinary tract infection, in the setting of having kidney stones. She required inpatient admission for continued treatment with intravenous fluids and pain control, intravenous fluids, antibiotics, specialist consultation, as well as further evaluation with additional treatments as needed. Management of nephrolithiasis includes pain control, management of urinary tract infection, and stone retrieval if necessary. Indications for hospitalization include urinary obstruction, infection, and the need for parenteral fluid and pain management because of severe pain. The decision making at the time of admission was consistent with her young age, the presence of a complex medical condition, the persistence of symptoms despite appropriate treatment in the emergency department, and the need for ongoing intravenous hydration, pain control, treatment of infection, and close monitoring for potential deterioration of clinical status.