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

Diagnosis: Abdominal pain
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a woman who presented with abdominal pain, nausea and vomiting. She has a history of prior sleeve gastrectomy performed for the condition of morbid obesity. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the epigastrium. The white blood cell (WBC) count was slightly elevated at 11.9. The complete metabolic panel identified elevated alkaline phosphatase, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and bilirubin. A computed tomography (CT) scan showed gallstones and findings of cholecystitis. An abdominal ultrasound also showed gallstones without ductal dilatation or wall thickening. She was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. 

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with abdominal pain, nausea and vomiting. She was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The indication for cholecystectomy was established and surgery was performed. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered at a lower level. This level of care would have provided for ED (Emergency Department) assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Rhinosinusitis.

Treatment: 31256-50 (nasal/sinus endoscopy, surgical with maxillary antrostomy - bilateral procedure) , 31254-50 (nasal/sinus endoscopy, surgical with ethmoidectomy partial[anterior] - bilateral procedure), and 31237-79-50 (nasal/sinus endoscopy, surgical with biopsy polypectomy or debridement (separate procedure) - unrelated procedure by same physician during the postoperative period - bilateral procedure), endoscopic sinus surgery (ESS).

The insurer denied coverage for 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS).

The denial is overturned.

The patient evaluation states a six-year history of chronic rhinitis, nasal congestion, sinus congestion, constant mucus buildup, and sinus pressure. Prior treatment with Flonase and other nasal sprays for months, 3 courses of antibiotics per year for the past few years, and saline irrigations. Allergy testing was negative. Examination with endoscopy indicates 2+ turbinate, and 2+ adenoids. Assessment included chronic sinusitis. Plan is azelastine nasal spray. Sinus computed tomography (CT) scan report states polypoid tissue right maxillary sinus, mucosal thickening ethmoid sinus, narrow ostiomeatal units, bilateral Haller cells, and deviated septum. Follow-up evaluation is consistent with acute sinus inflammation treated with antibiotics and steroids. Operative report included bilateral endoscopic anterior ethmoidectomy and maxillary antrostomy. Postoperative evaluation indicates patient using saline sprays and included CPT (Current Procedural Terminology) 31237 postoperative sinus debridement.

The peer-reviewed literature does support improvement in health outcomes.

Damm, M., et al. (2002) stated "The leading complaints within the symptom profile of patients with chronic rhinosinusitis are airway obstruction and postnasal drip. The restriction of quality of life in patients with chronic rhinosinusitis is mainly caused by these symptoms, which can be improved in excellent fashion by functional endoscopic sinus surgery in the majority of patients, achieving better quality of life in the long term."

This patient is a good candidate for codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS).

There is documentation in the available medical record of symptoms of chronic rhinosinusitis affecting quality of life, failure of appropriate medical therapy, examination and CT scan findings consistent with chronic rhinosinusitis for which codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS) are the best available treatment for this patient at this time.     

The requested service codes 31256-50, 31254-50, and 31237-79-50 endoscopic sinus surgery (ESS) is likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

The carrier's denial of codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Rhinosinusitis.

Treatment: 31256-50 (nasal/sinus endoscopy, surgical with maxillary antrostomy - bilateral procedure) , 31254-50 (nasal/sinus endoscopy, surgical with ethmoidectomy partial[anterior] - bilateral procedure), and 31237-79-50 (nasal/sinus endoscopy, surgical with biopsy polypectomy or debridement (separate procedure) - unrelated procedure by same physician during the postoperative period - bilateral procedure), endoscopic sinus surgery (ESS).

The insurer denied coverage for 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS).

The denial is upheld.

This was a woman with a history of sinus disease. She was seen as an outpatient. She stated that she had chronic rhinitis for the last years. She stated that she used Flonase and other nasal sprays for months at a time, but there was no real change. She feels congested in her nose and sinus and there is a constant mucus build up. There is daily pressure in sinus. She notes that she has taken at least three courses of antibiotics each year for the past few years for intermittent infections. The patient felt that the pressure and other symptoms were getting worse.

The patient's medical history is consistent with the diagnosis of chronic rhinosinusitis which was refectory to medical treatment. The one documented example in the information available of the physical examination is inconsistent with the diagnosis of chronic rhinosinusitis. The CT (computed tomography) obtained did not find chronic recurrent sinusitis. From the information available the diagnosis of chronic rhinosinusitis [CRS]does not fulfil the guidelines of the American Academy of Otorhinolaryngology - Head and Neck Surgery4.   

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome (2,5-8) if there was documented evidence of CRS.

This patient was not a good candidate for codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS) as she did not have documented CRS.

Codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS) were not the best available treatment for this patient at this time as she did not have documented CRS. There are numerous other interventions which could have been utilized for the case of CRS.  The adverse risks do increase over standard treatment/services.

The carrier's denial of codes 31256-50, 31254-50, and 31237-79-50, endoscopic sinus surgery (ESS) should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever

Treatment inpatient stay

The insurer denied coverage for inpatient stay.

The denial is overturned.

The patient presented to the emergency department (ED) with fever, nasal congestion, cough, and emesis. She had a generalized seizure in the waiting room while waiting to be seen. Temperature was recorded as 104 Fahrenheit.

Although no virus was identified, she had a presumed viral illness, with leucopenia (3600) as supporting evidence.  Her febrile viral illness was causing her metabolic acidosis and dehydration. Incidentally, the final urine culture result did not confirm a urinary tract infection, as it was a mixed low colony count of E [Escherichia] coli and E (enterococcus) faecalis, and urinalysis showed no white blood cells.

Although most children with a simple febrile seizure can be discharged safely to home once they have returned to normal alertness and muscle tone, some require hospital admission for safer medical care, depending upon exacerbating factors, which could trigger a recurrence in the short term, even as soon as the baby goes home. One of these factors is the severity of the underlying febrile illness. In the case of the patient, the hydration status was a major factor. (See Discharge Disposition section in UpToDate, referenced below). She continued to be highly febrile through her stay in the ED, which put her at increased for further dehydration and acidosis. Although the plan was to send her home, a clinical recheck and review of labs highlighted a low bicarbonate level of 14.4, which would need to be rechecked and monitored. Moreover, there were physical signs of moderate dehydration, clearly documented in the Pediatric notes, which required further IV (intravenous) fluid therapy.

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

The inpatient stay was considered medically necessary for this patient.

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

The insurer's denial of coverage for the inpatient stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-COPD/Chronic Obstructive Lung Disease
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient was admitted to the hospital for a chronic obstructive pulmonary disease (COPD) exacerbation. The question at hand is whether the patient met medical necessity for the acute inpatient level of care. She has a history of hypertension (HTN), asthma, COPD, emphysema, tobacco use, chronic respiratory failure on home oxygen, and anxiety. On presentation she had four days of worsening dyspnea. Vitals noted an oxygen saturation of 82% (per cent) on room air. Labs noted a white blood cell count (WBC) of 15.2. Chest x-ray noted changes consistent with COPD. She was started on intravenous (IV) steroids, bronchodilators, IV antibiotics, and supplemental oxygen. Pulmonary was consulted. The patient clinically improved and was stable at discharge. 

The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to the Global Initiative for Chronic Obstructive Lung Disease (2020), National Institute for Health and Care Excellence (NICE) (2018), and Wedzicha et al., (2017), the patient did have a clinically significant COPD exacerbation with persistent hypoxia and wheezing and is dependent on oxygen at home. The patient received IV steroids, bronchodilators, IV antibiotics, supplemental oxygen, and consultation with a pulmonologist. A lower level of care would not have been appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: DVT (deep vein thrombosis)

Treatment Eliquis (apixaban).

The insurer denied coverage for Eliquis (apixaban).

The denial is upheld 

This patient has a history of hypertension, asthma, hypothyroidism, malignant melanoma, gastroesophageal reflux disease, DVT (deep vein thrombosis), pulmonary embolism (PE), and Factor 5 Leiden mutation, heterozygous. The treating provider is requesting Eliquis.

Per visit note, the patient had a DVT in the lower extremity, and possibly a PE. With workup, it was determined he had a Factor 5 Leiden deficiency, and it was elected to not continue with lifelong coumadin.

"No studies have performed direct pairwise comparisons of the effectiveness and safety of warfarin and the new oral anticoagulants (NOACs) apixaban, dabigatran, and rivaroxaban. Using 2013 to 2014 claims from a 5% random sample of Medicare beneficiaries, we identified patients newly diagnosed with atrial fibrillation who initiated apixaban, dabigatran, rivaroxaban, warfarin, or no oral anticoagulation therapy ...Outcomes included the composite of ischemic stroke, systemic embolism (SE) and death, any bleeding event, gastrointestinal bleeding, intracranial bleeding, and treatment persistence. We constructed Cox proportional hazard models to compare outcomes between each pair of treatment groups. The composite risk of ischemic stroke, SE, and death was lower for NOACs than for warfarin: hazard ratio (HR) 0.86, 95% [percent] confidence interval (CI) 0.76 to 0.98 for apixaban; 0.73, 95% CI 0.63 to 0.86 for dabigatran; and 0.82, 95% CI 0.75 to 0.89 for rivaroxaban, all compared with warfarin. There were no differences in effectiveness across NOACs." (Hernandez et al.,).

The formulary drugs, warfarin and Xarelto are not likely to cause the patient an adverse reaction. The patient has already been treated on warfarin, and as this is going to be lifetime treatment, warfarin would not be appropriate.  Xarelto is an equivalent option to Eliquis therefore, would not be likely to cause an adverse reaction.      

Eliquis and Xarelto are similar drugs that are considered to be equally effective; therefore, there is no reason to use Eliquis over Xarelto at this time in this patient.

The insurer's denial of Formulary Exception for Eliquis (apixaban) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Loss of Consciousness

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves an adult female who presented to the emergency department (ED) complaining of shaking and a loss of consciousness. The documentation indicated she presented after having 3 episodes of loss of consciousness. She also had an episode of urinary incontinence in triage. There were no postictal findings noted on physical examination. She was immediately responsive after shaking resolved. There are no neurological deficits on exam, and she was alert and oriented to person, place, and time. It was suspected she was having partial seizures. It was recommended she undergo laboratory studies in addition to diagnostic studies. The documentation indicated on exam there was a small slow frequency tremor in both upper and lower extremities however was able to stop upon command of movement. The concern was high for space-occupying lesion of brain, epilepsy, pseudoseizure, or substance abuse. Laboratory studies revealed a white blood cell (WBC) count of 7.2 with red blood cell (RBC) count of 4.89. Potassium was 4.5 and her anion gap was 13. Her urinalysis did reveal trace leukocytes. The computed tomography (CT) scan was unremarkable. It was recommended she be admitted and loaded with Keppra in addition to undergo additional consultations. She did undergo additional testing to include an EEG which was normal. She did remain seizure-free on Keppra for greater than 24 hours. She denied any further adverse events during stay. No other significant instabilities were noted and given a period of hemodynamic stability she was discharged.

According to referenced literature, the requested inpatient stay was not medically warranted.  The documentation indicated the patient initially presented after having 3 episodes of loss of consciousness. However, upon admission and initiation of medication, the documentation does not detail any further significant issues. The patient remained stable and given the lack of significant deficits, the inpatient admission is not needed. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Inflammatory bowel disease (IBD).

Treatment: current procedural terminology code (CPT) 80145, adalimumab serum levels and antibodies to adalimumab

The insurer denied coverage for current procedural terminology code (CPT) 80145, adalimumab serum levels and antibodies to adalimumab

The denial is overturned

This patient is diagnosed with Crohn's disease of both small and large intestine without complication.

The patient was seen regarding a history of Crohn's disease.  The patient was doing well overall reported no issues with fatigue, emesis, diarrhea, hematochezia, or nausea.  He was consistent with Humira and reported no problems with injections.  The patient remained active in extracurricular activities and did not have a hard time keeping up.  On examination, there was no neurological or musculoskeletal abnormalities.  The patient was to continue Humira.

According to a letter, the patient was under the care for inflammatory bowel disease.  The patient currently receives adalimumab for treatment and required measurement of adalimumab drug and antidrug concentrations.  The patient required therapeutic drug monitoring.

The American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) Guidelines approve the utilization of drug monitoring to optimize care.  This is particularly helpful in adolescents where one wants to optimize within a biologic class before switching.  Therefore, the requested medication is likely to be more beneficial than any other standard therapy and there are no increased risks. 

The carrier's denial of current procedural terminology code (CPT) 80145, adalimumab serum levels and antibodies to adalimumab should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Inflammatory bowel disease (IBD).

Treatment: current procedural terminology code (CPT) 80145, adalimumab serum levels and antibodies to adalimumab

The insurer denied coverage for current procedural terminology code (CPT) 80145, adalimumab serum levels and antibodies to adalimumab

The denial is overturned

The patient has Crohn's disease. He has been on Humira, and it has been controlling his disease. A serum adalimumab level was obtained and was 7.0

The American Journal of Gastroenterology article titled "Clinical utility of measuring infliximab and human anti-chimeric concentrations in patients with inflammatory bowel disease concludes that measuring infliximab concentrations and antibody levels is clinically useful. Increasing the drug dose may be a good strategy if lnfliximab levels are subtherapeutic.

Clinical Gastroenterology and Hepatology article titled "Appropriate Therapeutic Monitoring of Biologic Agents for Patients with Inflammatory Bowel Disease states that consensus was achieved towards the utility of therapeutic drug monitoring of biologics in inflammatory bowel disease (IBD), particularly anti-tumor necrosis factor (TNF) therapy. For anti-TNF therapies, proactive therapeutic drug monitoring was found to be appropriate after induction and at least once during maintenance therapy.

This patient has Crohn's disease and is on biologic therapy with adalimumab. The use of therapeutic drug monitoring has been shown to be able to optimize the treatment of Crohn's patients on anti-TNF (tumor necrosis factor) therapy. The scientific peer reviewed literature supports the use of therapeutic drug monitoring as a means of improving health outcomes. The test has been used pursuant to CLIA (clinical laboratory improvement amendments) regulations for clinical purposes. The patient is a good candidate since he is a teenaged child and requires optimization of his biologic therapy. Measuring serum and antibody levels is useful for patient management and has no adverse risks. Obtaining therapeutic monitoring of anti-TNF drug levels is well established as part of the management of patients with Crohn's disease. 

This medication is likely to be more beneficial than any other standard treatment without increased risk over standard therapy.

The carrier's denial of current procedural terminology code (CPT) 80145, adalimumab serum levels and antibodies to adalimumab should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care.
 The insurer denied Increase in Personal Care Aide (PCA) Level 2: 7 hours per day-7 days per week-for a total of 49 hours per week for medical necessity.
 The denial is overturned.

The patient is a female with a past medical history significant for hypothyroidism, prediabetes, transient ischemic attack (TIA), diastolic heart failure, rheumatoid arthritis, gastroesophageal reflux disease, sick sinus syndrome, coronary artery disease, sleep apnea, asthma, hypertension, osteoporosis, lumbar stenosis, and dyspnea on exertion. She has been currently approved for 35 hours a week and additional services were denied by the Plan for medical necessity. The patient is appealing the decision for assistance on weekends.
The nurse assessment noted the patient requires set up for eating and required limited assistance for medication management. The patient required extensive assistance for dressing upper body, personal hygiene, bed mobility, walking, locomotion, toilet transfer and toilet use. She requires maximal assistance for dressing lower body, bathing, female preparation, and total dependence for housework. She has a bedside commode, cane, shower chair, shower grab bar, walker, and incontinence supplies.
At issue is the medical necessity of Increase in Personal Care Aide (PCA) Level 2: 7 hours per day-7 days per week-for a total of 49 hours per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Increase in Personal Care Aide (PCA) Level 2: 7 hours per day-7 days per week-for a total of 49 hours per week is medically necessary for this patient.
The patient lives alone in a 1-bedroom apartment and reports that the rest of her family lives out of state. She is an elderly female with worsening physical health based upon the 2 assessments. The patient needs significant assistance for Instrumental activities of daily living (IADL)s and extensive assistance for most activities of daily living (ADL)s. The patient has a patient care assistant (PCA) 7 hours per day times ()5 days a week. She has medical needs on the other 2 days a week when an aide is not present. These needs include personal hygiene, bed mobility, walking, locomotion, and toilet transfer. The patient also has no informal helpers available. The patient required extensive assistance for dressing upper body, personal hygiene, bed mobility, walking, locomotion, toilet transfer and toilet use. She requires maximal assistance for dressing lower body, bathing, female preparation, and total dependence for housework. The patient needs additional services on the 2 days that the PCA is not present.
Therefore, the requested health service/treatment of Increase in Personal Care Aide (PCA) Level 2: 7 hours per day-7 days per week-for a total of 49 hours per week is medically necessary.