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

Diagnosis:  Musculoskeletal pain.
Treatment:  Physical therapy visits, procedure code 97161.

The insurer denied coverage for physical therapy visits, procedure code 97161.  The denial is upheld. 

This is a female patient with complaints of generalized full body musculoskeletal pain; including but not limited to neck, back, arms and legs.  Imaging studies failed to demonstrate any correlated pathology.  Treatment includes analgesic/muscle relaxant medications and physical therapy.  Currently under review is the medical necessity of physical therapy visits, procedure code 97161 to be provided.

The submitted physical therapy treatment notes made available for review provide insufficient objective clinical information to support the medical necessity for the requested physical therapy.  The clinical records do not establish the medical necessity of continuing a structured out-patient physical therapy treatment program.  There is limited, if any, specific documentation of a functional physical impairment or evidence of quantifiable functional improvement.  This reviewer agrees with the insurer, particularly as it relates to the lack of documented quantitative functional improvement as a result of the physical therapy treatment provided.  The health plan acted reasonably, with medical judgment or in the best interest of the patient in this particular case.  

The medical necessity for physical therapy visits, procedure code 97161 to be provided is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioblastoma; Headaches
Treatment: Electrical stimulation device
The insurer denied the electrical stimulation device.
The denial is overturned. 

The patient is a female. She has history of glioblastoma. She presented with headaches. The patient underwent craniotomy. Pathology revealed WHO (World Health Organization) grade IV glioblastoma. The patient underwent resection followed by chemoradiation. The patient has now been recommended Optune device for further treatment.

Yes, the Electrical Stimulation Device is medically necessary.

The patient is a candidate for the use of Optune, as they have recurrence of GBM (glioblastoma multiforme) after previous resection and best medical therapy. This has been approved by the FDA (Food and Drug Administration) for this patient type and has been shown to be safe and effective. The use of Optune is medically necessary and within the standard of care for this type of patient and therefore should be approved. The established benefits have been shown in trials, and it is considered to be within the standard of care.

Optune is appropriate and medically necessary for this patient and should be approved for TT (tumor treating) Fields in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Constipation and urinary retention.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

This female was admitted through the emergency room (ER) with constipation and urinary retention.  A catheter was placed with a post-void residual (PVR) of 800 milliliters (mL).  Over the next three hours she made 1400 cubic centimeters (cc) of urine, consistent with a post-obstructive diuresis.  The creatinine was 0.46.  The white blood cell (WBC) count was 7260.

No, the inpatient admission was not medically necessary.

Care after an uncomplicated Foley catheter placement for urinary retention can be provided at an observation level of care.  Because there were no signs of infection, excessive bleeding, or instability an acute inpatient level of care was not necessary.  An acute inpatient level of care was not medically necessary based on the surgeries performed and their uncomplicated post-operative course.  She was at low risk of destabilization from a post-obstructive diuresis after the first 24 hours.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease/Asthma
Treatment: Pharmacy/Prescription Drugs (Symbicort)
The health plan denied the Prescription Drugs (Symbicort).
The health plan's determination of medical necessity is upheld, in whole.

The patient is a female with a history of chronic obstructive pulmonary disease (COPD) with asthma overlap and ongoing tobacco use. Control of her airway disease improved after she was switched from Breo 100-25 to Symbicort 160/4.5. She apparently had tried generic Symbicort and did not tolerate it (increased wheezing and dyspnea).

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

It is not medically necessary, as above. Although true generics may involve different devices or excipients which can affect a patient's response to or tolerance of the medication, an authorized generic is the exact same formulation, both active and inactive ingredients with no difference between the two. There is no reason that the authorized generic Budesonide-Formoterol should function any differently than brand name Symbicort. As such, the health plan has acted reasonably. The authorized generic is the exact same medication.
As listed in the citations, further supported by the following citation, [5] these authorized generics are completely bioequivalent with the brand name. Generics can sometime have different excipients or devices, but the authorized generics have the exact same active component, excipients, and device, and so there truly is no difference between the authorized generic and the brand name inhaler. As such, the brand name inhaler would not be medically necessary as the authorized generic is identical in every way.  The studies cited also supports the exactly equivalent nature of the authorized generics and thus the lack of medical necessity for the brand name version.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Pain Management, Facet Joint Injections, Outpatient Procedures (64490 x 2, 62291x 2, and 64492 x 2).
The insurer denied coverage for Pain Management, Facet Joint Injections, Outpatient Procedures (64490 x 2, 62291x 2, and 64492 x 2).
The denial is upheld.

This is a female patient with neck pain, back pain, obstructive sleep apnea (OSA), degenerative joint disease (DJD), and coronary artery disease (CAD). The patient had a telemedicine visit with an orthopedic nurse practitioner (NP). The patient complained of ongoing mid-back pain. The patient's pain was rated at a level of 5 out of 10 with medication and 10 out of 10 without medication. The patient was able to perform activities of daily living (ADLs) with medication. The patient appeared to be in no acute distress. The patient had physical therapy (PT) with no relief. The treating practitioner recommended applying ice, applying heat, and stretching. The patient had a follow up visit; she still reported pain and the treating practitioner recommended thoracic medial branch block steroid injections. 

Manchikanti et al. (2018) reviewed the evidence level supporting thoracic facet diagnostic and therapeutic blocks, and stated, "The awareness that facet joints can be a cause of chronic mid back and upper back pain is a relatively recent development (since 1987). With appropriate investigations, using controlled diagnostic medical branch blocks, thoracic facet joints have been established as sources of mid back pain, upper back pain, and referred pain into the chest wall and abdominal wall in patients with chronic thoracic pain (evidence Level II). The evidence for therapeutic facet joint nerve blocks is Level II; the evidence for radiofrequency neurotomy is Level IV. There is no established evidence for managing chronic thoracic pain with therapeutic intra-articular injections."

Gungor et al. (2020) described the anatomic difficulty of performing diagnostic, medial branch block in the thoracic region. Gungor et al. (2020) states, "The anatomy of thoracic zygapophyseal joint and its innervation variability when compared with the lumbar region makes it difficult to benefit from [traditional heat radiofrequency (TRFA)]. Anatomically, the location and number of medial branches are significantly different than those of the lumbar spine. The medial branches of the thoracic spine are more than 1 nerve per level and are dispersed mainly in the superior and lateral aspect of the transverse processes."

As per literature review above, the requested injections are not supported by the imaging and the ability to reliably diagnose thoracic facet dysfunction by injection is also uncertain. The requested procedure is thus, not considered medically necessary for this patient.

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

The medical necessity for the Pre-Service request for Pain Management, Facet Joint Injections, Outpatient Procedures (64490 x 2, 62291x 2, and 64492 x 2) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Benign prostatic hypertrophy (BPH); Urinary frequency.
Treatment: Tadalafil 5mg tablet.
The insurer denied coverage for Tadalafil 5mg.
The denial is overturned. 

This male patient has a past medical history of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) with frequency and nocturia. He is currently managed with Uroxatral (alfuzosin) 10 mg daily. The patient reported that his nocturia had improved on this treatment, but daytime frequency was unchanged, and the patient complained of double voiding. Office visit notes revealed that the patient had been previously given tamsulosin which did not help his urination and affected him sexually. The patient's prostate-specific antigen (PSA) was 0.6.  Further discussion revealed that the patient was not interested in surgical intervention and wanted to try daily Cialis (tadalafil) 5 mg tablet as alternative to Uroxatral.  

The insurer stated that the patient has not tried and failed two formulary drugs, as required to be eligible for Tadalafil coverage for treatment of benign prostatic hyperplasia (BPH)/Lower Urinary Tract Symptoms (LUTS). 

Based on the review of the medical records and literature, Tadalafil 5mg is considered medically necessary for this patient. The patient does not need to try formulary alternatives such as finasteride, which is a 5-alpha reductase inhibitor, type of medication. The Food and Drug Administration (FDA) approved Tadalafil 5 mg once daily for treatment of benign prostatic hyperplasia (BPH).  

The coverage of Tadalafil 5 mg is considered medically necessary for this patient.

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

Based on the above, the medical necessity for Tadalafil 5 mg is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a male with a past medical history (PMH) of asthma who presented with acute appendicitis with free fluid. He had a white blood cell (WBC) of 18 and transaminitis. The original plan was for antibiotic management, however, he was still in pain so underwent a laparoscopic appendectomy. His operative report indicates there was no gangrene or perforation. He was discharged to home. The inpatient admission is under review.

The inpatient hospital admission was not medically necessary. The patient required intravenous (IV) antibiotics and IV fluid hydration, and nausea treatment. This could be delivered in most centers at a lower level of care. 
Level II evidence from NSQIP (National Surgical Quality Improvement Program) in pediatric patients concludes: Outpatient management following appendectomy in children is possible with low morbidity and readmission rates. Comparison with other NSQIP-Pediatric centers suggests an opportunity to generalize this practice with considerable savings to the health care system.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

This female presented to the emergency department complaining of a 30-minute episode of palpitations with a feeling of confusion, mild dyspnea, and diaphoresis. During this episode she noticed that her neck veins appeared to be distended. Her medical history was remarkable for anxiety. She reported having had a similar episode.
An echocardiogram at that time showed no structural heart disease. In the emergency department her blood pressure was 119/68 millimeters of mercury (mmHg) with a heart rate of 92 beats/minute. Her respiratory rate was 16 breaths/minute. Her room air oxygen saturation was 100%. Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin level was normal, as was her chest x-ray. A point of care echocardiogram was normal.
She was admitted to the hospital. She remained in sinus rhythm with an episode of sinus tachycardia. She was discharged the next day.
At issue is the inpatient hospital stay for medical necessity.
The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
Palpitations, the sensation of one's heart beating rapidly, irregularly, or forcefully, are a common presenting complaint in the emergency department. The potential causes range from benign to malignant. While more often benign, they can be an indication of a serious arrhythmia. Factors associated with a higher risk of serious arrhythmias include structural heart disease, syncope, and a family history of sudden cardiac death.
This woman presented after a 30-minute episode of palpitations. She was hemodynamically stable and in a sinus rhythm. Her cardiac exam and electrocardiogram were normal. Her chest x-ray and serum troponin level were normal. A point of care echocardiogram was also normal. Thus, this patient had no features suggesting she was at high risk for a serious arrhythmia. No particular treatment was required. After an overnight monitoring period the patient was discharged. The care she received did not require an inpatient admission.
Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Issue under review: Comprehensive orthodontic treatment

Determination:
The Comprehensive orthodontic treatment is medically necessary.

The patient is an adult female requesting orthodontic benefits.

The patient has a crossbite of an anterior tooth (#27) with an associated attachment (gum) loss as a result. This is an "automatic qualifier" according to the handicapping index scale. Orthodontic treatment is needed to correct this problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Varicose Veins. 
Treatment: Surgical Services-RFA. 

The health plan denied the requested service/treatment of Vein procedure as not medically necessary. 

The reviewer has overturned in whole the health plan determination. 

The patient presents with left lower extremity symptomatic varicose veins. Her main symptoms include pain and swelling. She has attempted and failed conservative therapy with graded compression stockings for at least six weeks duration. Per the patient she has also attempted exercise and elevation to relieve the symptoms. Per the patient, her symptoms interfere with her activities of daily living. She is also noted to have brownish discoloration on physical examination. Her duplex scan demonstrates reflux in her left small saphenous vein. Her provider is recommending endovenous ablation of the left small saphenous vein for treatment of her condition. 

Endovenous ablation of the left small saphenous vein is Medically Necessary based on the clinical submitted for review, peer reviewed literature, and standard of care. 
There is sufficient documentation included to justify Medical Necessity for endovenous left small saphenous vein ablation for this patient. Endovenous ablation of the refluxing small saphenous vein is the current standard of care treatment for patients with symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results. 

Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent c.i. 680 to 820), 599 (521 to 677) and 813 (751 to 876) per cent respectively after 1 year.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diffuse Body Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history (PMH) of sickle cell disease with a prior history of acute coronary syndrome (ACS) status/post (s/p) exchange transfusion and avascular necrosis (AVN) s/p right total hip replacement (THR) and was admitted with c/o diffuse body pain. Of note, the patient was seen for similar complaints the day before admission and discharged home after a negative work-up. Vital signs were unremarkable. The physical exam was notable for acute distress, but not ill or toxic appearing, and right knee swelling. Lab work was remarkable for a stable hemoglobin. A right shoulder radiograph showed no acute pathology, magnetic resonance imaging (MRI) showed tendonitis. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with musculoskeletal (MSK) pain and treated with intravenous (IV) fluids, by mouth (PO) nonsteroidal anti-inflammatory drugs (NSAIDs), hydroxyurea, and a lidocaine patch. The patient was discharged in stable condition with physical therapy (PT). At issue is the medical necessity of an inpatient stay. 

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the ED with complaints of diffuse body pain and was diagnosed with a sickle cell crisis. The patient did not have any concerning qualities that would make a lower level of care inappropriate, including fevers or clinical suspicion of infection, hypoxia, hypotension, acute kidney injury, acute chest syndrome, stroke, refractory priapism, or other serious co-morbid condition. The patient was evaluated by the admitting physician and it was determined that, given the patient's presentation,  the pain was likely not related to sickle cell pain and was most likely related to MSK pain, and she was treated for pain with non-opioid analgesics. Overall, this patient clinically stable patient was admitted for MSK pain and treated with non-opioid pain control and IV fluids, and discharged within 24 hours, all of which could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female who presented to the emergency department after an episode of palpitations and pleuritic chest pain with associated lightheadedness and dyspnea. The palpitations lasted approximately 30 minutes; the duration of the chest pain was 15 minutes. Her blood pressure was 139/75 millimeters of mercury (mmHg) with a heart rate of 114 beats/minute. Her respiratory rate was 19/minute with a room air oxygen saturation of 100%. Her temperature was 100.2 degrees Fahrenheit (F). On physical exam the patient was obese; the exam was otherwise unremarkable. Her white blood cell count was 12,800/cubic millimeters (cumm). Her chest X-ray and serum troponin level were normal. An electrocardiogram showed sinus tachycardia without acute changes. A Covid-19 test was negative as was a test for influenza. The patient was treated with acetaminophen and admitted to the hospital with diagnoses of palpitations and chest pain. Blood cultures were negative. She had no further chest pain and was discharged. Medical necessity for an inpatient stay is at issue. 

The health plan's determination is upheld. 

This patient presented with chest pain and palpitations. She had a low grade fever and mild leukocytosis. As far as her chest pain, it was atypical for ischemia, her electrocardiogram showed no acute changes, and her serum troponin level was normal. Based on her HEART score she was at low risk for major adverse cardiac events. An inpatient level of care was not warranted on the basis of her chest pain. 
Regarding the patient's palpitations, she was in sinus rhythm upon presentation. Her electrocardiogram was normal other than mild sinus tachycardia. Her cardiac exam and chest X-ray were normal. The record does not mention recurrent syncope or a family history of sudden cardiac death. There was no evidence that this patient was at increased risk for a potentially malignant arrhythmia. An inpatient level of care was not warranted on the basis of her palpitations. 

The patient had a low grade fever and mild leukocytosis. There was no evidence of acute bacterial infection or sepsis. She was not treated with antibiotics and her temperature decreased to normal. An inpatient level of care was not warranted based on her fever and leukocytosis. 

The patient could have been managed at a lower level of care status.