Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Major Depressive Disorder-Recurrent-Severe

Treatment: Pristiq (desvenlafaxine ER)

The insurer denied coverage for Pristiq (desvenlafaxine ER)

The denial is overturned

 
This adult reportedly had depressive symptoms including depressed mood and had a diagnosis of Major Depressive Disorder-Recurrent-Severe without psychotic features and the request was for non-formulary Pristiq (Brand name for desvenlafaxine ER) 50 mg (milligram) and 25 mg for treatment of major depression. She reportedly had tried many past anti-depressant medications with reports of side effects and intolerability or lack of efficacy. It was reported that genetic testing showing that Selective serotonin reuptake inhibitors (SSRI's) were not well tolerated or effective and that Serotonin-norepinephrine reuptake inhibitors (SNRI's) such as Pristiq were. This patient reportedly was taking Pristiq for years with reported efficacy and tolerability, so the request was to continue with Pristiq.
  
The insurer denied coverage for non-formulary Pristiq 50 mg and 25 mg (brand name Desvenlafaxine Succinate ER) stating that she needed to try formulary medications including generic desvenlafaxine, venlafaxine, or duloxetine and have reported lack of efficacy, intolerability, or contraindication to them.
 
The medical records provided enough specific evidence to support that she required this medication and that it was medically necessary to treat her major depressive symptoms and disorder. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Major Depressive Disorders reports that there are several different classes of antidepressant medications Food and Drug Administration (FDA) approved for the treatment of major depressive disorder including serotonin norepinephrine reuptake inhibitors (SNRI's) and Pristiq is a serotonin norepinephrine reuptake inhibitor (SNRI) that is FDA approved for the treatment of major depressive disorder. 

She reportedly met the insurer's formulary exception criteria as well as she had lack of tolerability and lack of efficacy to 3 formulary medications including generic desvenlafaxine, venlafaxine, and Duloxetine. 

The requested nonformulary medication, Pristiq, was considered to be more effective and tolerated as she reportedly was taking this with efficacy and tolerability for many years, so this was specific evidence that this medication was considered more effective and tolerated than the formulary medication that she tried and had side effects and intolerability to and lack of efficacy.  

The formulary drugs have been ineffective based on the patient's clinical history.

The formulary drug is likely to cause the patient an adverse reaction. 

The requested drug would be more effective than the formulary drugs.

As a result, the recommendation is to overturn the previous decision and approve the request for non-formulary Pristiq (brand name desvenlafaxine ER) 50 mg and 25 mg for treatment of major depressive disorder. 

The carrier's denial of a request for a Formulary Exception for Pristiq (desvenlafaxine ER) is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mobility issues
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 84 Hours per Week
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 84 Hours per Week. The health plan's determination is overturned. 

This is a case review for a male with medical history notable for mobility issues and heart disease. The patient and his care team requested an increase in personal care assistant services to 84 hours per week. A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in his apartment. He was alert and oriented to person and place only; he was forgetful and confused at times. His decisions were described as poor and unsafe and he requires cues and supervision at all times. For his Instrumental activities of daily living (IADL), he requires total dependence for meal preparation, housework, and shopping. He requires maximal assistance for stairs and transportation. He requires extensive assistance for finances, medications, and phone use. For his activities of daily living (ADL), he requires maximal assistance for bathing and toilet use. He requires extensive assistance for dressing, walking, locomotion, and toilet transfer. He requires limited assistance for hygiene, bed mobility, and eating. He is incontinent of urine with no control present. He is continent of stool. He does not have any skin breakdown. A task tool associated with the assessment recommended 46 hours per week to address his personal care needs.

The requested Consumer Directed Personal Assistance Services (CDPAS): 84 Hours per Week is medically necessary for this patient.
The patient suffers from multiple medical conditions and has a generalized functional decline. He requires assistance with ambulation and toileting and is incontinent of urine. His personal care needs are expected to be continuous and unscheduled throughout the day. Furthermore, he has an aortic dissection and is not a candidate for surgical repair; overexertion could exacerbate his condition. Therefore, the requested increase in CDPAS hours is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Back surgery (27279 x 1) - sacrum. 
The insurer denied back surgery (27279 x 1) - sacrum. 
The health plan's determination is upheld. 

This is a male with a history of low back and leg pain and a prior L (lumbar) 4-S (sacral)1 fusion. He has had physical therapy, injections and medications without relief. A  right SI (sacriliac) joint injection provided 30% (percent) relief for one day. He is a non-smoker. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows spondylolisthesis with severe spinal stenosis at L3-4. The provider has recommended a right sacroiliac joint fusion.

Back surgery is not medically necessary. The patient has had one documented right SI joint injection that gave only 30% relief of symptoms temporarily. There does not appear to have been another injection in the records provided. Additionally, the patient has spondylolisthesis and severe spinal stenosis at L3-4 which is the adjacent level to his prior fusion. This is a potential source of pain. 
Based on these findings, the procedure is not medically necessary as it does not meet the NASS (North American Spine Society) criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: surgical procedure on the stomach and inpatient hospital admission

The insurer denied coverage for surgical procedure on the stomach and inpatient hospital admission

The denial is overturned

 
The patient is an adult with hyperlipidemia and fatty liver. She has a body mass index (BMI) of 36. She has been seen and approved for surgery by her Bariatric surgeon, dietician and psychologist. She underwent cardiac risk stratification. She has been deemed a good candidate for surgery. The patient has tried and failed multiple weight loss attempts including weight watchers, protein shakes, portion control, exercise and meal prepping. Request for bariatric surgery, laparoscopic gastric sleeve (LGS) has been made.

In their Final Adverse Determination letter, "Criteria from the guideline named "Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy". This can be found in the nationally recognized medical reference called Milliman Care Guidelines (MCG) (26th edition). Based on the information provided, these criteria are not met, because: Your records do not show that you have the required weight or weight-related conditions to meet these criteria: A body mass index (BMI, ratio of weight relative to height) greater than 40, or a BMI greater than 35 with certain clinically serious conditions related to obesity (type 2 diabetes, obesity breathing problems, sleep breathing problems, a liver condition called nonalcoholic steatohepatitis, severe arthritis, uncontrolled hypertension on three blood pressure medications (including one water pill), or requiring four medications for good control), or a BMI greater than 30 with uncontrollable diabetes despite optimal medical therapy Medical necessity for this service has not been established."

According to the denial letter, surgery is indicated when there is a comorbidity such as obstructive sleep apnea (OSA), diabetes mellitus (DM) 2 or fatty liver disease. The patient has an ultrasound (US) submitted showing that she had fatty liver disease. Therefore, the patient has a qualifying comorbidity for surgery.      

The surgical procedure on the stomach and inpatient hospital admission are considered medically necessary for this patient.

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

The medical necessity for surgical procedure on the stomach and inpatient hospital admission services is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Congestion Syndrome
Treatment: Vascular Embolization or Occlusion Inclusive of Radiological Supervision 
The health plan denied the vascular embolization or occlusion inclusive of radiological supervision.
The health plan's determination is overturned.

The patient is a female patient that has persistent non-cyclical pelvic pain that radiates to her back and abdomen. The pain has become so severe that she has had to change occupations and she severely limits her quality of life. The pain worsens with standing, sitting and exercises. There is associated worsening with pain during menstrual cycles and intercourse.

The vascular embolization or occlusion inclusive of radiological supervision is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The embolization procedure has been shown to be safe and effective in treating patients with her symptoms and anatomy. There are no other standard options for care of a patient with these imaging and clinical findings/symptoms.

The health plan's determination is overturned in whole. This patient has symptoms and imaging findings that are consistent with pelvic venous incompetence (also known as pelvic congestion syndrome). Her symptoms are lifestyle limiting and affect her quality of life. These symptoms have already limited her ability to work. Embolization is a safe and effective treatment option to treat the dilated veins that are the cause of the patients' symptoms. This is the only treatment option available that is shown to be effective and can performed with minimal sedation on an outpatient basis with a negligible recovery period.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Congestion Syndrome
Treatment: Vascular Embolization or Occlusion Inclusive of Radiological Supervision 
The health plan denied the vascular embolization or occlusion inclusive of radiological supervision.
The health plan's determination is overturned.

The patient is a female patient with a history of pelvic varices that are symptomatic. Her pain is persistent in the pelvis and worse with exercise, intercourse, standing and sitting. She needs a pelvic iliac and ovarian venogram with embolization performed. Pelvic venous reflux is present. An ultrasound was performed. The magnetic resonance imaging (MRI) of the pelvis was performed. The computed tomography (CT) imaging was performed.

Her past medical history was reviewed. Her pertinent past medical records were reviewed. Her past surgical history was reviewed. The patient's medications were noted as evaluated. The current treatment plan requires the embolization and other companion procedures be performed.

Given the patient's diagnosis and current health status, the proposed treatment or health service or occlusion of targeted venous vessels in the pelvis inclusive of radiological supervision is more likely to be beneficial than any other treatment or treatments for the insured's life threatening or disabling condition or disease namely pelvic varices.
The requested procedures are medically necessary for this patient. The patient has a history of symptomatic pelvic varices. This is the standard of care and the standard treatment. Symptomatic pelvic varicosities can be a terribly disabling diagnosis and a medical problem that should not be ignored but rather requires a meaningful treatment attempt.

The health plan's determination of medical necessity regarding the proposed health service or treatment is overturned in whole. This patient meets accepted criteria in the literature for treatment for this diagnosis.

The requested procedure is not considered to be experimental, investigational or unproven for the condition of symptomatic pelvic varicosities and would have superior clinical outcomes to other treatments in comparison. This would include comparison to analgesic medications, hormone manipulation and surgery such as hysterectomy or venous ligation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Congestion Syndrome
Treatment: Vascular Embolization or Occlusion Inclusive of Radiological Supervision 
The health plan denied the vascular embolization or occlusion inclusive of radiological supervision.

The health plan's determination is upheld.

The patient is a with a 1.5 year history of pelvic pain exacerbated by exercise, menstruation, standing, and intercourse. She had an imaging workup (ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI)) that showed prominent bilateral adnexal vessels and ovarian vein reflux. The provider wishes to perform ovarian vein embolization as a treatment for the patient's pelvic pain.

Under review is whether vascular embolization or occlusion inclusive of radiological supervision is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

There is a lack of peer-reviewed literature supporting ovarian vein embolization as being more beneficial than standard medical treatments for this condition.

The health plan's determination regarding the proposed health service/treatment is upheld. The health plan is not responsible to reimburse for treatments that are not supported as superior to standard medical therapy, and thus can be considered "experimental". The body of evidence in the peer-reviewed medical literature regarding embolization of the Ovarian Vein or Internal Iliac Veins for the treatment of pelvic congestion syndrome (PCS) is insufficient and poor quality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of obesity and diabetes mellitus type 1 (DM1) who was admitted with complaints of (c/o) a two-week history of dysuria associated with flank pain, fevers, and chills. Her vital signs were notable for a temperature (T) of 102.3 degrees Fahrenheit, and pulse 124. The physical exam was notable for non-toxic appearing, left flank tenderness to palpation (TTP). Lab work was notable for hyperglycemia, leukocytosis, no urinalysis (UA) pyuria or leukocyte esterase (LE), negative urine culture. Imaging studies included a computed tomography (CT) scan of the abdomen/pelvis (A/P) which showed enlarged kidneys concerning for a urinary tract infection (UTI). The patient was diagnosed with sepsis secondary to pyelonephritis and treated with intravenous (IV) antibiotics and intravenous fluids (IVF). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care.

This patient presented to the emergency department (ED) with complaints of (c/o) dysuria associated with flank pain, fevers, and chills. The patient was hemodynamically stable, did not meet systemic inflammatory response syndrome (SIRS) criteria, did not have an acute severe kidney injury, toxic appearance, unstable vital signs, immunosuppression, urinary obstruction, coexisting urolithiasis, failure of outpatient treatment, was not residing in a long-term care facility, abnormal anatomy, abscess formation, single kidney, or kidney transplant. The patient did have tachycardia and a fever, which resolved with treatment, and the patient's leukocytosis improved. Overall, this patient was found to have a UTI and was treated with intravenous (IV) antibiotics and IVF, with resolution of the patient's symptoms, and these interventions could have been safely and appropriately provided at a lower level of care. The patient did not have hemodynamic instability, altered mental status (AMS), pregnancy, kidney transplant, significant uropathy, infection of prosthetic device, ureteral obstruction, impaired bladder emptying, renal abscess, pyonephrosis, or acute renal failure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This patient had an acute episode of low back pain.  He could not walk and could not drive. His initial work up in the Emergency department revealed that he was Covid 19 positive and had a new lucency in the lumbar (L)1 vertebral body.  He required intravenous opiates and Toradol for pain control. A magnetic resonance imaging (MRI) showed annular fissures in 2 discs which would explain his symptoms, and he was discharged the next day.

The Milliman Care Guidelines (MCG) specifically state as a reason for admission: "Severe pain requiring acute inpatient management".  The use of intravenous narcotics requires close monitoring.

Further, a new lesion at L[lumbar]1 needed investigation in the setting of acute pain to rule out a neoplastic process. Not being able to walk is a RED FLAG2 and needed to be worked up beyond an emergency or observation only visit.

The admission was medically reasonable and necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent dental decay
Treatment: fixed partial denture
The insurer denied coverage for fixed partial denture.
The denial is overturned.

This is an elderly female patient who suffers from issues with manual dexterity concerns and is under the care of her dentist. The patient had a fixed bridge from teeth 19-21 and lost this fixed bridge due to recurrent dental decay. The treatment planned for an implant retained fixed bridge in the same area. The partial denture would have been difficult per the dentist.      

The custom fabricated abutment- includes placement (D6057) and abutment supported retainer for porcelain/ceramic FPD (fixed partial denture) (D6068) is considered medically necessary for this patient. The titanium implant bridge will replace the prior prosthesis and allow for maximal function. The partial is much more difficult to utilize. 

Per American Academy of Implant Dentistry, "A resin-bonded bridge looks and functions better than a removable denture but isn't as strong as fixed bridgework and typically doesn't function or last nearly as long as dental implants."

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 custom fabricated abutment- includes placement (D6057) and abutment supported retainer for porcelain/ceramic FPD (fixed partial denture) (D6068) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented to the emergency department with a history of abdominal pain. There was no associated nausea or vomiting. Vital signs were within normal limits with the exception of a heart rate of 134 beats per minute (bpm). White blood cell count was elevated to 12.5. A computed tomography (CT) of the abdomen and pelvis demonstrated acute tip appendicitis. The right ovary was noted to be enlarged and displaced to the midline with engorgement of adjacent ovarian vessels. Findings were suspicious for ovarian torsion. A pelvic ultrasound demonstrated a large right ovary with cysts. General surgery and obstetrics/gynecology were following and managing the patient. The patient underwent a laparoscopic appendectomy and right ovarian cystectomy. There was noted to be 20 cubic centimeters (cc) of pus in the anterior and posterior cul de sac. The right ovary had a simple appearing cyst which had ruptured with clear fluid. There were no reported postoperative complications. 

Admission after appendectomy may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., COPD [chronic obstructive pulmonary disease], chronic heart failure), or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care. Milliman Care Guidelines (MCG) criteria indicate that admission is indicated after ovarian cystectomy for conversion to an abdominal procedure, surgical complications, ovarian torsion, intestinal obstruction, or comorbidities [6]. There were no immediate complications documented after the surgery. There was no evidence of ovarian torsion. Peer-reviewed literature also indicates that outpatient laparoscopic appendectomy can successfully be performed in those with uncomplicated appendicitis. Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications. [4, 5] Surgical documentation notes that the patient was uncomplicated. Therefore, the requested inpatient hospital stay was not medically necessary. Observation care would be more appropriate.

The health plan acted reasonably. The patient underwent an uneventful laparoscopic appendectomy and right ovarian cystectomy and was discharged on the following day. There were no reported complications. Outpatient appendectomy is safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation [1-3]. 

Based on the above, the insurer's denial must be upheld. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Back Pain
Treatment: 64628 Intracept Procedure
The insurer denied: 64628 Intracept Procedure
The denial is upheld.

The patient is an adult female with axial and radiating low back pain to her buttock and at times to the level of the toes. She had undergone two lumbar transforaminal epidural steroid injections with minimal benefit and the Intracept is being requested due to Modic changes noted at L3 (Lumbar) and L4.

The health plan should not cover the proposed treatment.

The Intracept procedure when done for vertebrogenic pain has adequate literature and research for support that would benefit. However, this patient has extension-based pain and stenosis. The extension-based pain has not been treated with facet treatment such as radiofrequency ablation for the medial branch nerve blocks. Extension based positive facet grind is not an indication for the Intracept procedure. It is an indication for facet-mediated injections. Therefore, the health plan should not cover the proposed treatment.