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

Diagnosis: Cardiac/Circulatory Problems-Stroke/CVA
Treatment: Home Health Care-Personal Care Aide (PCA)
The health plan denied the increase in personal care aide hours as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history of chronic obstructive pulmonary disease, coronary artery disease, hyperlipidemia, diabetes mellitus type 2, hypertension, gastroesophageal reflux disease, hypothyroidism, depression, insomnia, peripheral vascular disease, osteoarthritis, elevated prostate-specific antigen and urinary incontinence who had been assigned personal care aide (PCA) services 7 hours/day, 7 days/week to total 49 hours/week based on assessment tool. The patient was admitted to the hospital with cerebrovascular accident (CVA) with resultant hemiparesis of right side. The patient was subsequently admitted to a Skilled Nursing Facility (SNF). The patient underwent a telephonic assessment tool. The assessment stated the patient had declined in his ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's physician provided a letter stating the patient needed an increase in Home Health Aid (HHA). The patient's primary care physician (PCP) provided a letter stating the patient's condition had significantly deteriorated. The patient had been hospitalized 9 times and has progressively worsened with mental and functional capabilities. 

The requested increase in PCA hours to 12 hours per day, 7 days per week, for a total of 84 hours per week is medically necessary for this patient. 

The patient has documented significant change in functional status following a CVA. There is documentation of increased assistance needs for tasks of ordinary housework, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating when comparing assessments. The patient's PCP's letter states the patient has had worsening in functional status since the last home care assessment. The patient requires PCA services outside of the time he has informal support. The patient has unscheduled and unpredictable care needs that span a continuum of time and the previous denial failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with current PCA hours and/or adaptive equipment and/or medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. PCA services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervicalgia

Treatment Aimovig 70 milligram per milliliter (mg/ml) subcutaneous (SC) solution auto injector (SOAJ)

The insurer denied coverage for Aimovig 70 mg/ml SC SOAJ.

The denial is overturned.

Aimovig has been recommended for this patient due to a diagnosis of cervicalgia migraines and post-concussion syndrome.  The documentation indicated she has approximately 30 headache days a month with 15-20 migraine days.  The documentation indicated prophylactic medications were not helping to prevent and control migraines.  She has utilized topiramate which was ineffective for migraine prevention, and she has also trialed and failed Imitrex and Wellbutrin.  The documentation indicated this medication has been recommended to help prevent her migraines.  Note indicated the patient had complaints of worsening headaches and stated she was utilizing topiramate as well as riboflavin and magnesium.  She stated she utilizes Imitrex 1-2 times a month and will also utilize Tylenol and ibuprofen as needed.  She also reported worsening blurry vision to both eyes and was wanting a referral to neuro-ophthalmology.  The physician indicated her headaches may be in part due to medication overuse and it was recommended she cut down on abortive medications to include Tylenol and ibuprofen to no more than 2 days a week.  The physician indicated she should be seen to rule out papilledema.  She was recommended to go to the emergency department if her headache becomes severe.

According to the literature, this medication is a preventative Calcitonin Gene Related Peptide (CGRP) Antagonists.  The submitted documentation does indicate this patient has failed Topamax as well as Wellbutrin for prevention.  She has 15-20 headaches per month and therefore it would be very reasonable for her to try the requested medication for headache prevention.  As discussed in the Headache Society consensus statement, this patient qualifies for the use of Aimovig. Therefore, the prior denial should be overturned.

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 Aimovig 70 mg/ml SC SOAJ to treat migraines is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male with a history of hypertension, coronary artery disease (CAD), diabetes and transient ischemic attack (TIA) who was admitted to the hospital. He initially presented with worsening shortness of breath and lower extremity edema. He underwent cardiac cath at an outside hospital and was found to have three vessel coronary artery disease. He also had mitral valve disease and was referred for percutaneous coronary intervention (PCI) versus cardiac bypass graft surgery along with mitral valve replacement. Recent COVID-19 testing was negative. Vital signs showed blood pressure 170/91, heart rate 107, temperature 98.4 Fahrenheit, and respiratory rate 18. On physical exam, heart was regular, a systolic murmur was audible, breath sounds were normal, and lower extremity edema was present. An electrocardiogram (EKG) showed sinus tachycardia with premature ventricular contractions. Labs showed glucose 154, sodium 137, creatinine 1.4, white blood cell (WBC) 9.1, hemoglobin 11.4, and platelets 293. The patient was admitted for PCI. 

The inpatient admission is overturned. The patient underwent a complex PCI procedure in the setting of mitral valve disease, and concerns for heart failure and bronchospasm. Even though the patient was discharged on the second hospital stay, complex PCI procedures are frequently complicated by chest pain and concerns for acute cardiac ischemia. The patient's need for diuresis and bronchodilators also increased overall risk. It would not be appropriate to manage a clinical situation of this complexity at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Back pain.
Procedure: Surgical Services-MILD procedure.

The health plan denied the MILD procedure.  The reviewer has upheld in whole the health plan's determination.

This is a patient with intermittent neurogenic claudication due to central lumbar spinal stenosis. The patient has failed conservative measures including physical therapy, nonsteroidal anti-inflammatory medications, and epidural injections. A magnetic resonance imaging (MRI) scan of the lumbar spine revealed mild grade 1 retrolisthesis Lumbar(L)5. Spondylitic changes that can be correlated with patient symptoms. Findings are worse than prior. Spinal stenosis at L4 - L5 is considered severe. Back pain rated at approximately 5/10. The lumbar interlaminar epidural steroid injections with 50% pain relief lasted one month. The pain is exacerbated at this time. Current medications for pain include meloxicam. Physical examination revealed limited painful range of motion. Motor strength is 5/5 in the bilateral lower extremities, sensory exam is intact. Plan was physical therapy, continue medication, and the MILD (minimally invasive lumbar decompression) procedure.

Per evidence based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not Recommended (generally)NR. Not recommended. MILD (minimally invasive lumbar decompression), from Vertos Medical, Inc., describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the MILD procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (e.g., without endoscopic or microscopic visualization of the work area). This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required. Due to the unknown impact of these limitations on health outcomes, randomized controlled trials (RCTs) in appropriate patients are needed to compare this new procedure with established alternatives... systematic review found that current evidence does not support the routine use of minimally invasive surgery for cervical or lumbar discectomy. Minimally invasive surgery had no clinically significant advantage in terms of short- or long-term measures of pain or function. Patients who underwent minimally invasive disc surgery had higher levels of nerve root injury, dural tears, and reoperation. According to the authors, surgeons already perform open discectomies through relatively small incisions, so it is not surprising to find that outcomes are no better with minimally invasive discectomies."

The patient has chronic back pain and severe spinal stenosis and has failed conservative treatment including medication, physical therapy, and epidural injections. The requested procedure is not considered standard of care in the general medical community, as there are significant risks with this procedure, and it is not found to be more effective than that of a traditional open discectomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kienbock's disease.
Treatment: procedure code E0760, osteogenesis stimulator, low intensity ultrasound, noninvasive.

The insurer denied coverage for procedure code E0760, osteogenesis stimulator, low intensity ultrasound, noninvasive.  The denial is upheld. 

According to the documentation submitted, this is the case of a female with a history of Kienbock's disease and a contusion of the right wrist. She presented to the Orthopedist's office with complaints of pain in both wrists. Pain at rest was rated at a level of 2 and pain with movement was rated at a level of 5. In the past the patient was treated with Exogen, copper gloves, magnets, and topical creams. A physical examination of the right hand revealed wrist swelling and tenderness. There was tenderness over the first carpometacarpal (CMC) joint. Wrist dorsiflexion and volar flexion were to 30 degrees. The left wrist was also swollen with tenderness over the first CMC joint.

The osteogenesis stimulator in this case is not medically necessary for this patient, as there is no peer reviewed literature showing efficacy of low intensity pulsed ultrasound in the treatment of chronic wrist pain or Kienbock's disease. According to a recent review in the Journal of the Academy of Orthopaedic Surgeons, conservative management of Kienbock's disease consists of immobilization and anti-inflammatory medication. Low intensity pulsed ultrasound is not mentioned.

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

The carrier's denial of coverage for the procedure code E0760, osteogenesis stimulator, low intensity ultrasound, noninvasive should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatitis C.
Treatment: Epclusa.

The insurer denied Epclusa. The health plan's determination is overturned.

The patient is a male with chronic Hepatitis C, genotype 1 and decompensated cirrhosis. He also has Hepatitis B co-infection with no viral load and positive surface antigen. He has a medical history of gastrointestinal bleeding, coronary artery disease, and anemia (baseline hemoglobin of 12.8 and 11.7). Viral load was 998,000. He has treatment-naive for Hepatitis C. Coverage is being requested for Epclusa 400/100 milligrams (mg) daily for 24 weeks for the treatment of chronic Hepatitis C, genotype 1.

Epclusa (Sofosbuvir/Velpatasvir) is medically necessary for this patient.

The current medical literature does support the use of Epclusa monotherapy for this patient. According to guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions (Class I, Level A recommendation). Patients with cirrhosis are reported to be high priority for treatment. The guidelines recommend that genotype 1 patients with decompensated cirrhosis should be treated with Epclusa and ribavirin for 12 weeks. The guidelines also state that for decompensated hepatitis C virus (HCV) patients who are ribavirin ineligible, Epclusa is supported for 24 weeks, as supported by clinical trial data showing efficacy. Ribavirin can result in the rapid development of anemia.

In this case, the patient has coronary artery disease and existing anemia; worsening of his existing anemia in the setting of coronary artery disease can result in significant clinical consequences. The use of Epclusa should have similar efficacy to Epclusa with ribavirin for 12 weeks, but the use of ribavirin would not be appropriate in this already anemic patient with coronary artery disease. For these reasons, the request for Epclusa is supported as medically necessary for the treatment of this patient's chronic Hepatitis C.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Linzess 145 micrograms (mcg). 
The denial is upheld.

The patient is a female under evaluation and management for chronic idiopathic constipation (CIC). The patient was treated on fiber supplements which were not beneficial for constipation and caused nausea. According to the provider the patient tried Miralax twice daily (BID) which was helpful but stopped on her own. There are no pharmacy claims for fiber or Miralax so she was presumably using both over-the-counter (OTC). She had a good response to samples of Linzess. The patient's provider requested Linzess 145 micrograms (mcg). This request was denied by the plan as the patient had not met medical necessity criteria.

The health plan's determination is upheld in whole. 

Linzess is not medically necessary. The patient responds adequately to Miralax BID. This is documented in the medical record. She has gone back to using it now that there has been a delay in getting Linzess approval. There is no specific advantage for Linzess over Miralax for the treatment of CIC. There is currently no documented failure of Miralax. It is well documented that that she failed fiber.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This female patient presented to the hospital with chest pain lasting for 12 hours and radiating to both shoulders. Past medical history was significant for hypertension and remote deep vein thrombosis (DVT) and pulmonary embolism (PE).  Physical exam revealed blood pressure (BP) 154/89, pulse of 65 beats per minute (bpm) and no abnormal findings. Electrocardiogram (ECG) revealed sinus rhythm with non-specific T wave changes. The patient was admitted to the hospital for further testing and treatment. Serum blood testing revealed no elevation in troponin (<0/01).  Echocardiogram revealed a normal left ventricular ejection fraction (LVEF) of 65% [percent] without wall motion abnormalities.  Stress myocardial perfusion testing revealed no evidence of ischemia with MPHR [maximal age predicted heart rate] >than 85%. She was subsequently discharged the day after presentation with follow up. 

The health plan acted reasonably and with sound medical judgement and in the best interest of the patient. Inpatient hospital admission was not necessary for this patient that presented with chest pain.  Her pretest probability of coronary artery disease is intermediate.(1)  Utilizing the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score he was considered intermediate risk (4 points). (2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3) Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (4,5)  They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. (5)  Inpatient hospital admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental caries.
Treatment: D6010 - surgical placement of implant body tooth #31. 

The insurer denied coverage for D6010 - surgical placement of implant body tooth #31. 

The denial is upheld. 

Based on review of the submitted documentation which includes copies of pretreatment panoramic radiographs, post treatment periapical radiograph, dental charting, dental clinical notes, copies of photographs of study models, narrative letters it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation in the right mandible, #31 (2nd molar) area.  #31 was deemed non maintainable due to caries and was extracted.  The doctor recommended subsequent endosteal implant to be placed at the site.  The insurer has denied the service stating that in their estimation the current circumstance does not fulfill the medical necessity criteria as per the Medical Policy coverage and therefore the endosteal implant is considered not medically necessary and no benefit is available.  The patient is appealing the decision. 

Upon review of the objective documentation, as regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient there may be circumstances where implants might be considered elective services, as in this case the patient's occlusion is stable and reproducible to the molar areas. Replacement of #31 is therefore considered elective and not medically necessary for proper function. 

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

The insurer's denial of coverage for code D6010 - surgical placement of implant body tooth #31 is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Hospital Admission
The insurer denied coverage for hospital admission
The denial is upheld

The patient presented to the emergency department with complaints of left forearm infection following a tattoo placement.  Vitals on presentation included: Temperature 98.7 Fahrenheit, Blood Pressure 133/80, Pulse 73, Respiratory Rate 17, oxygen (O2) saturation 99 percent (%) on Room Air. Laboratory results included the following: White blood cell count (WBC)10.0, hemoglobin (HGB)-16.5, hematocrit (Hct)-47.3, creatinine-0.82, glucose-140.

The patient was started empirically on intravenous antibiotics (clindamycin) for possible left upper extremity cellulitis. The patient remained afebrile, clinically, and hemodynamically stable. He was discharged to continue oral antibiotics (clindamycin) as an outpatient.

According to documentation, patient presented with possible left arm cellulitis after getting a tattoo. Otherwise, patient remained afebrile, hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Patient had a localized infection and no surgical intervention was necessary. Based on above findings, patient did meet criteria for observation level of management. He did not fulfill criteria for acute hospital admission.
  
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld.  Medical Necessity is not substantiated.