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

Diagnosis: Cirrhosis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.
 
The patient presented with abdominal pain and distention. He was afebrile and the vital signs were stable. His abdomen was distended with ascites, but there were no peritoneal signs. There was no leukocytosis. He was diagnosed with alcoholic cirrhosis. The plan was for diuretics and a paracentesis. A paracentesis was not consistent with Spontaneous bacterial peritonitis (SBP), and antibiotics were not necessary. He was not in acute withdrawal. The patient decided to leave against medical advice (AMA). 

Medical necessity was determined based on Milliman Care Guideline (MCG) M-570 for Liver Disease. Clinical indications for admission include having acute liver failure as manifested by an [international normalized ratio] INR over 1.5 or hepatic encephalopathy, hemodynamic instability, persistent tachypnea after observation care, infected ascites, hepatorenal syndrome, severe vomiting that is not responsive to treatment, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had a history of alcohol abuse and now presented with ascites. He required a paracentesis and diuretic therapy. This could have been done with observation status. He was not in acute liver failure and had an INR of 1.26. He did not meet MCG criteria for admission for Liver Disease. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

The denial is upheld.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.

Treatment: Carotid ultrasound study (93880).

The insurer denied coverage for Carotid ultrasound study (93880).

The denial is upheld.
 
Asked to review the case of an adult female that presented to the doctor with symptoms of chest pain, shortness of breath, lightheadedness and near syncope.  On examination, pulse was 85, Blood Pressure 110/80. No abnormalities were noted on physical examination. The patient had a past medical history of cardiomyopathy and a left ventricle ejection fraction (LVEF) of 36% (percent) noted on cardiac magnetic resonance imaging (MRI).  She was treated with low dose beta blocker (Toprol XL 25 milligrams (mg)) and ramipril (1.25mg) with subsequent recovery of left ventricular function.  Holter monitor, exercise stress test and carotid duplex were ordered to assess near syncope. Exercise stress testing was significant for 1-2 millimeters (mm) down sloping ST segment depression in the inferior leads and premature ventricular contractions (PVCs) during exercise. Symptoms of dizziness/lightheadedness were reproduced during exercise. Insurer has denied coverage for CPT 93880- bilateral carotid duplex study.  

This patient presented with complaints of lightheadedness and near syncope. She had no history of stroke or transient ischemic attack (TIA) and no evidence of focal neurologic findings on examination. Moreover, symptoms were reproduced during exercise stress testing.  Current guidelines do not recommend carotid artery imaging in routine evaluation of patients with syncope in the absence of focal neurological findings (Class III indication). (Reference 1,2). The diagnostic utility of carotid artery duplex ultrasonography has been demonstrated to be a low yield test in the evaluation of patients with syncope. (Reference 3) In conclusion, carotid ultrasound study, current procedural terminology (CPT) code 93880 is not medically necessary for this patient.

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 carotid ultrasound study, current procedural terminology (CPT) code 93880 is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Psoriasis.
Treatment:  Sotyktu.

The insurer denied Sotyktu.  The health plan's determination is upheld. 

The patient is a female with diffuse psoriasis, including the scalp. The patient has tried and failed topical Clobex, Derma-Smoothe, and clobetasol shampoo. As per the clinic notes, the patient consumes less than one drink of alcohol per day. 

A formulary exception is not indicated in this case.

The patient has no documented treatment failure with, or true medical contraindication to, either Methotrexate, Acitretin, Otezla, Cosentyx, Enbrel, Humira, Cimzia, Skyrizi, Stelara, or Tremfya, all of which are of similar potency and efficacy to the requested Sotyktu. These plan alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition as is the requested Sotyktu. These alternative medications are as effective, and with no significantly greater incidence of adverse effects, as the requested Sotyktu.

The modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Sotyktu, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and this literature recommends use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, a formulary exception is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis

Treatment: Surgical Procedure on the Thigh Region and Knee Joint; outpatient surgery 27447 x (times) 1, 20985 x (times) 1

The insurer denied coverage for Surgical Procedure on the Thigh Region and Knee Joint; outpatient surgery 27447 x 1, 20985 x 1.

The denial is overturned.

The patient was seen in the clinic with complaints of a 56-year history of bilateral knee pain.  The patient reports constant pain and states they cannot do any bending or lifting without getting severe swelling in both knees. The patient works as a construction manager, and this has significantly affected their ability to work. 

The medical records were consistent with end-stage osteoarthritis with functional limitation. It was extremely important to recognize the presence of a severe gait abnormality. There was also the presence of contracture and limited extension. The patient was found to have crepitus, crouched gait and deformity. The patient's physician also reported the flexion and varus deformity on X-rays. X-rays done showed large bilateral patellofemoral compartment osteophytes and smaller bilateral medial tibial femoral compartment osteophytes. The impression was extensive degenerative changes.  A full course of conservative treatment was also provided including over 3 months of physical therapy and maximum doses of anti-inflammatory medications with no improvement in symptoms. The patient has also failed multiple injections. Based upon the clinical description, surgery would be appropriate and necessary. 

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

The medical necessity for Surgical Procedure on the Thigh Region and Knee Joint; outpatient surgery 27447 x 1, 20985 x 1 is substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Class II Division 1 malocclusion with severe maxillary and mandibular crowding
Treatment: Braces, Monthly Visits, and Retainer 
The insurer denied Braces, Monthly Visits, and Retainer 
The health plan's determination is overturned. 

The patient in question is a young female with a Class II Division 1 malocclusion with severe maxillary and mandibular crowding. She has 7 millimeter (mm) overjet and 5mm overbite. She has lip incompetence at rest. Tooth 22 is in crossbite. 

Braces, Monthly Visits, and Retainer are medically necessary for this patient.
Tooth 10 is in crossbite with tooth 22. Additionally, tooth 22 is being pushed labially in the dental arch and is developing recession. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. These problems are much more time consuming to correct than the patient's current orthodontic problem.
This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. In her particular case, teeth 7-10 are very proclined. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ (plus) mm overjet, which this patient has. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male with past medical history significant for hypertension, hyperlipidemia and diabetes mellitus. The patient presented to the emergency room with complaints of pain and redness to the left lower extremity. The patient reported that his left leg started becoming red, warm and swollen and developed tenderness starting at the ankle. The patient was evaluated by his doctor later and was prescribed Keflex that he was taking as advised. The patient reports that symptoms worsened while he was on the antibiotics, he also developed fever (104 F (Fahrenheit)) at home, and he also noticed the redness spreading up to the thigh. The patient presented to the emergency department and was admitted to the clinical decision unit (CDU) under cellulitis protocol - he was started on intravenous Ancef and doxycycline. Laboratory studies were significant for: sodium of 129, platelet count 95, and neutrophil count 76.4. The patient was admitted to the clinical decision unit for intravenous antibiotics with minimal improvement status post 2 days of Cefazolin and doxycycline. The patient had been afebrile in the clinical decision unit, blood cultures were sent and were still processing, and the patient was admitted to medicine for further management of left lower extremity cellulitis. 
On day #3, the patient developed fever and was seen by Infectious disease and antibiotics were changed to Unasyn and Linezolid. The patient continued to slowly improve and was discharged home.

The requested inpatient hospital admission was medically necessary.

Inpatient medical admission was appropriate for the above duration. The patient presented with symptoms of worsening lower extremity cellulitis in spite of taking antibiotics (Keflex) and he was febrile at home. The patient was started on intravenous antibiotics and was followed in the clinical decision unit. He had minimal improvement over the next 24 to 48 hours. In view of 
this, the patient was admitted to inpatient hospital stay for continued intravenous antibiotics. In view of minimal improvement over the first 24 to 48 hours in spite of intravenous antibiotics, it was clear that patient needed to continue intravenous antibiotics and also that he needed monitoring to ensure that he continued to respond and improve on the intravenous antibiotics. On day #3, the patient was febrile and evaluated by Infectious Disease consult who advised a change of antibiotics to Linezolid and Unasyn. In view of this, inpatient medical admission was medically appropriate to ensure continuation of intravenous antibiotics (Ancef every 8 hour), to ensure that the patient continued to respond and to be able to adjust the antibiotic regimen if needed, based on the clinical response.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Comprehensive Dental Treatment

Treatment: Bridge Coverage

The insurer denied coverage for bridge coverage.

The denial is upheld.

Upon review of the submitted documentation which includes copies of undated panoramic radiographs dated, narrative letter/physician attestation, and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation, the aforementioned treatment of fixed bridges was recommended. As per the attestation, the areas of involvement for bridge placement appear to be the right maxilla and right mandible. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support the requested services. 

Based on the submitted objective information for review, which consists solely of the panoramic radiographic examination, it is evident that the patient exhibits a heavily restored dentition with endodontically treated teeth and numerous fixed crown and bridge prostheses. The radiographs do not indicate any significant pathology such as recurrent caries or other issue regarding the preexisting restorations that would necessitate this extensive treatment plan. The full coverage restorations in place appear to be intact and well adapted. Although in the attestation it is reported that the patient underwent several extractions of teeth this is not reflected in the documentation submitted. As this is the case, and there is no other objective clinical documentation provided for review, the radiographic documentation does not support the dental treatment recommended by the dentist. There are no dental treatment notes, no dental charting, nor periodontal charting provided for review. As the documentation is inadequate to support the treatment, these services are considered not medically necessary.

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 bridge coverage is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypotension, Syncope
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who initially presented to the emergency department with concerns for hypotension and near syncope. The symptoms rapidly resolved upon returning to bed. The pertinent history included cryoglobulinemia, prior cerebrovascular accidents with residual right-sided weakness (wheelchair dependent), bladder obstruction status/post (s/p) suprapubic catheter, and recurrent urinary tract infections on chronic antibiotic suppression.The initial examination documented the patient as alert, oriented, and without focal neurologic deficits. Orthostatic vital signs were positive. Fluid resuscitation was provided. The patient was admitted to the hospital. The admitting physician had an impression of orthostatic hypotension with no end organ damage and pre-renal acute kidney injury that improved with fluids. The treatment plan included daily orthostatic vital signs, an echocardiogram, and consultations. Symptomatic orthostatic hypotension persisted. An echocardiogram was relatively unremarkable to explain the persistent orthostasis. Additional fluid resuscitation was provided and an abdominal binder was placed. The MRI brain did not reveal new acute changes. The patient was discharged. At issue is the medical necessity of a full hospital admission.

Yes. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was medically necessary for the entire admission.
Runser et al. published guidelines in regard to the evaluation and management of syncope. They suggest that hospital admission be considered if the patient has a clinical history suggestive of arrhythmic syncope, severe anemia, electrolyte abnormalities, electrocardiograph history suggestive of arrhythmic syncope, family history of sudden death, hypotension, severe structural heart disease, congestive heart failure, or coronary artery disease.[1]
The patient initially presented to the emergency department with concerns of hypotension and near syncope. Initial evaluation in the emergency department was relatively unremarkable for an acute pathology process or significant laboratory abnormalities, however, the patient had an acute kidney injury and recurrent symptomatic orthostatic hypotension treated with aggressive fluid resuscitation. Intravenous fluids were continued. An abdominal binder and compression stockings were administered. Additional diagnostic tests were pursued including an echocardiogram, MRI (Magnetic resonance imaging) of the brain and water deprivation (given concerns for diabetes insipidus) which were relatively unremarkable. Despite appropriate management, symptomatic orthostatic hypotension persisted beyond an observation care time frame. Therefore, clinical indications for admission to inpatient care were met.[2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis, osteoarthritis and depression
Treatment: Consumer Directed Personal Assistance Service Program (CDPAS) 49 hours/week. 
The insurer denied coverage for: Consumer Directed Personal Assistance Service program (CDPAS) 49 hours per week (hours/week). 
The denial is: Upheld
This is an adult with chronic medical problems including osteoporosis, osteoarthritis and depression. The patient lives alone in a private residence. The insurer previously approved consumer directed personal assistance service program (CDPAS) 35 hours/week. The request is for CDPAS 49 hours/week. 

The Uniform Assessment System (UAS), was reviewed. According to the Assessment, the patient's cognition is described as minimally impaired. The patient's ability to complete much of their Instrumental Activities of Living (IADL) tasks, such as meal preparation, ordinary housework and shopping, varies from limited to maximal assistance. The patient is reported to require extensive assistance for bathing. Limited assistance is noted to be needed for personal hygiene, dressing, locomotion, toilet transfer/use and ambulation (however, notes document the patient was able to stand and walk). The patient is independent with eating and bed mobility. The patient reports being occasionally incontinent of bladder and continent of bowel. The patient's ability to perform activities of daily living (ADL) and self-sufficiency has not changed over the prior 90 days. There were no reported falls over the prior 90 days.  

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested increase CDPAS to 49 hours/week. The patient's treating physician submitted a note indicating, "Patient has depression and severe osteoarthritis. Please increase home health aide (HHA) hours." There is also a treatment note. The patient presented with hip pain and "lower back pain for several weeks after heavy lifting." The doctor noted the patient "is able to stand and walk." The patient was described as "neat and clean; No mood swing; No memory problem," "No gait disturbance; No tremor." Based on the clinical records, the patient's health and safety are appropriately provided and maintained at home by the approved CDPAS 35 hours/week.  

From a physical medicine and rehabilitation perspective, increasing CDPAS from 35 to 49 hours per week is not medically necessary. 

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 Consumer Directed Personal Assistance Service program (CDPAS), 49 hours per week is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure
The health plan's determination is overturned.

The patient is a female with a history of chronic low back pain. She has been treated with massage, acupuncture, therapy, epidural injections, facet injections, facet ablation, lumbar discectomy non-steroidal anti-inflammatory drugs (NSAIDs), and muscle relaxers. Magnetic resonance imaging (MRI) of the lumbar spine revealed disc displacement and Modic changes. Her treating physician recommended Intraosseous Basivertebral Nerve Ablation Procedure. It was noted that opiates were not in the best interest of the patient considering her substance abuse history.

The proposed Intraosseous Basivertebral Nerve Ablation Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. A review of available up-to-date publications utilizing BVN (basivertebral nerve) ablation in the treatment of vertebral pain suggests that there is quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to evidence that BVN radiofrequency ablation (RFA) is superior to conservative care for pain reduction, at least at 3-month follow-up. Also, there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious AEs (adverse events) based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure
The health plan's determination is upheld.

The patient is a female with complaints of chronic low back pain. Her pain began over 6 years ago. Prior treatments have included acupuncture, therapy, lumbar spine surgery, lumbar injections, as well as medications. The pain impacts activities of daily living. Pain ranges from 6-8 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine reported Modic changes at L (lumbar)3-4, L4-5 vertebral bodies.

The proposed Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required for this procedure. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.