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

Diagnosis: Low back pain
Treatment: pain injections in spine.
The insurer denied pain injections in spine.
The determination is overturned.


The patient has a history of low back pain and radiculopathy. His treatments have included Tylenol, anti-inflammatories, gabapentin, oral steroids and epidural injections. The health plan denied the requested service as it has been more than 12 months since the first injection. This is not supported by the standard of care nor by any professional society or board. At issue is the medical necessity of the requested injections.

The requested health service/treatment of pain injections in the spine is medically necessary for this patient.
Injections of steroids directly into the epidural space are used for treatment of radicular back or neck pain after failure with conservative management. The steroids are given with or without anesthetic agents for relief of pain. Epidural steroid injections have been considered a generally accepted standard of medical practice for many years. The results of clinical trials have been mixed. Although short-term relief of radicular pain may occur, long-term outcomes vary. No more than three-four injections should be given in a six-month period.
Repeat injections after the initial therapeutic phase should be done at intervals of at least 2 months, provided that previous injections resulted in at least 50% (percent) pain relief or functional improvement for at least 2 months.
There is a risk of bleeding, infection or spinal cord injury with this invasive procedure. Some practitioners may give epidural steroid injections blindly, however, the use of fluoroscopy for visualization of needle placement has been shown to reduce the risk and complications of the procedure.
In this case the patient had persisting complaints despite conservative treatment with positive findings on imaging, therefore the epidural injection would be indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glioblastoma. 
Treatment: Skilled Nursing Facility. 
The insurer denied the Skilled Nursing Facility. 
The determination is upheld. 

The patient was admitted to the hospital for management of a brain malignancy (glioblastoma) and a right heel necrotic heel ulcer. Per the clinical documentation, the patient is a total assist for all activities including needing a Hoyer lift for transfers and is essentially bedbound per the physician documentation. He requires minimal wound care, which includes every two-hour repositioning, pulse low air loss mattress, off-loading the heels with pillows, Allevyn dressing to the right lower leg wound and Vashe dressing to the right lateral heel wound. 

At issue is the medical necessity of a skilled nursing facility.

No, the requested health service/treatment of skilled nursing facility is not medically necessary for this patient. This patient was admitted to the hospital for management of a brain malignancy (glioblastoma) and a right heel necrotic heel ulcer. Per the clinical documentation, the patient is a total assist for all activities including needing a Hoyer lift for transfers and is essentially bedbound per the physician documentation. He requires minimal wound care, which includes every two-hour repositioning, pulse low air loss mattress, off-loading the heels with pillows, Allevyn dressing to the right lower leg wound and Vashe dressing to the right lateral heel wound. There is no documentation that the patient requires skilled nursing or rehabilitation services that must be performed by a professional or technical personnel or that the patient requires skilled services on a daily basis five days in a week. In addition, there is no documentation that the patient has rehabilitation potential. Therefore, the requested health service/treatment of a skilled nursing facility was not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Dry eyes
Treatment: Xiidra
The insurer denied coverage for Xiidra.
The denial is upheld.

This is the case of an adult patient with a history of blurred vision to both eyes, dryness to both eyes, and newly suspected glaucoma. At the patient's Ophthalmology office visit it was noted that the patient has been using artificial tears 2-3 times a day for a month without relief. The doctor is recommending Xiidra twice daily.  

Visual acuities were 20/32 (pinhole to 20/25) right eye (OD) and 20/25 left eye (OS).  Exam showed trace blepharitis and 2+ meibomian gland dysfunction both eyes (OU). There was abnormal breakup time OU, trace superficial punctate keratitis (SPK) OD and 1-2+ SPK OS.  Diagnosis of dry eye syndrome OU was noted. The patient to continue artificial tears and initiate Xiidra.

In a letter the request for Xiidra was denied because the patient has not tried formulary alternative of Restasis.

The formulary drug (Restasis) is not likely to cause the patient an adverse reaction. There is no documentation that the patient has tried and failed Restasis or has had an allergic reaction to Restasis.

The formulary drug (Restasis) has not been ineffective based on the patient's clinical history. The patient was noted to have tried artificial tears, but there is no documentation of the patient having tried Restasis.

The requested drug (Xiidra) has not been shown to be more effective than the formulary drug (Restasis). Restasis is FDA (Food and Drug Administration) approved for dry eye syndrome and is indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with dry eyes. The use of Restasis is consistent with standard of care for the treatment of dry eyes (AAO (American Academy of Ophthalmology) preferred practice pattern 2016), and studies have shown that Restasis improves both the signs and symptoms of dry eyes (Stonecipher 2016).

The carrier's denial of Request for Formulary Exception for Xiidra is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary retention
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a male who presented with difficulty urinating and urinary retention.
He was well until 3 days prior to presentation when he developed fever. He was tested for viral illnesses at that time and was negative for COVID (coronavirus disease 2019), respiratory syncytial virus (RSV), and influenza. He continued to have fever up to 101.2 F (Fahrenheit) and also developed a pruritic facial rash. He then presented to the emergency department and had a straight catheterization performed for a urinalysis and culture. 

Inpatient Hospital Admission was medically necessary for this patient.
This is a young boy who presented with difficulty urinating and urinary retention following a straight catheterization procedure. He was initially crying in pain and had no void in more than 24 hours. An ultrasound revealed a significant volume of urine in the bladder, and therefore a straight catheterization was required. A urologist consultation was obtained and continued care with pain management, a bowel regimen, and straight catheterization as needed was recommended. He therefore required inpatient admission to provide this care along with close monitoring with additional evaluation and treatment as needed.

Complications of bladder catheterization can include urethral trauma and microscopic hematuria. In addition, catheterization can cause iatrogenic infection. This patient was crying in pain with urination after a catheterization procedure and was withholding urine. An appropriate specialist consultation was obtained and he was cared for in the emergency department, but he continued to be unable to void. He therefore required admission for ongoing care with straight catheterization, pain control, and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Chest pain.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Hospital Admission.
The denial is upheld. 

This male patient presented to the emergency department (ED) complaining of left-sided, nonexertional chest pain. His medical history was remarkable for hypertension, type 2 diabetes, and cocaine use. He reported noncompliance with his prescribed antihypertensive medication. His last cocaine use was four days prior to presentation. In the ED his blood pressure was 165/108 millimeters of mercury (mmHg) with a heart rate of 65 beats/minute. An electrocardiogram showed sinus bradycardia with nonspecific T wave abnormalities. His high sensitivity troponin level was normal. Chest X-ray showed no acute pathology. Urine toxicology was positive for cocaine and cannabinoids. The patient was treated with aspirin, a statin, clonidine, and sublingual nitroglycerin and admitted to the hospital. Upon admission his blood pressure was 148/94 mmHg. He had chest wall tenderness to palpation; his chest pain was thought to most likely be musculoskeletal in origin. Losartan and amlodipine, which he had been taking at home, were prescribed.
The patient's chest pain was improved; it was described as "mild". His blood pressure ranged from 135/84 mmHg to 165/90 mmHg. Hydrochlorothiazide, which he had also been taking prior to admission, was added. His serum troponin remained normal. He was discharged.
At issue is the medical necessity of Inpatient Hospital Admission.

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.
This man presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. While he was hypertensive upon presentation, there was no evidence of acute organ damage, and his blood pressure was controlled with oral medication. The care this patient received did not require an inpatient admission. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 American Heart Association (AHA) / American College of Cardiology (ACC) / American Society of Echocardiography (ASE) /CHEST/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gestational Hypertension

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient is a female with history of gestational hypertension, who presented 4 days postpartum with complaints of headache and elevated blood pressure (highest 175/105). Laboratory evaluation was normal. She was admitted with preeclampsia with severe features. She was started on magnesium sulfate for 24 hours. Labetalol 200 mg (milligram) was given twice a day (BID). Blood pressure improved. She was later discharged. 

This patient presented 4 days after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery. 

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:

1. Systolic blood pressure >=140 mmHg (millimeters of mercury) or diastolic blood pressure >=90 mmHg, (CONDITION MET) and 

2. Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, (CONDITION NOT MET) or 

3. Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL (millimeter per deciliter) or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration). (CONDITION NOT MET)

This patient had elevated blood pressure and a prior diagnosis of gestational hypertension. No protein in the urine was documented and no significantly elevated liver function tests and no end organ dysfunction. 

This patient did not have a diagnosis of preeclampsia. She had elevation in her blood pressure.  Ideally this patient would have been observed in the emergency department. Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

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

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

Diagnosis: Chronic Gastroesophageal Reflux Disease GERD. 
Treatment: Esophagogastroduodenoscopy (EGD) (code 43210). 

The insurer denied coverage for EGD (code 43210). 

The denial is overturned. 

The patient had chronic gastroesophageal reflux disease GERD. She was on proton pump inhibitor (PPI) therapy as well as Famotidine and continued to have symptoms. She was now considering anti-reflux surgery and had a DeMeester scope of 22. A laparoscopic hiataI hernia repair with transoral incisionless fundoplication TIF (transoral incisionless fundoplication) was performed. 

The American Society of Gastrointestinal Endoscopy (ASGE) has published a guideline on the role of endoscopy in managing GERD. The paper stages that the TIF procedure was approved by the Food and Drug Administration (FDA). It reports that 15 studies and 550 procedures found improved GERD health quality of life scores after the procedure. Three randomized trials with at least 6 months follow up found that TIF was more effective than high dose PPI therapy in eliminating regurgitation or extraesophageal symptoms of GERD. 

Healio Gastroenterology March 7, 2017, cites an article titled "SAGES provides strong recommendation for endoluminal GERD therapies." The Society of American Gastrointestinal and Endoscopic Surgeons performed a systematic literature review in 2016. The review found that compared to PPI treatment, TlF has clearly demonstrated to be more effective in controlling GERD symptoms 6 months after the procedure. 

Transoral incisionless fundoplication has been shown to be beneficial for patients with GERD who are not responding to PPI therapy. There are several options for endoscopic treatment of GERD, but TIF has been shown to be effective and safe. 

This patient has chronic GERD symptoms that are refractory to medical therapy. The medical literature supports the use of endoscopy with the TIF procedure. The health care plan did not act reasonably or with sound medical judgement. Doing an endoscopic procedure with CPT code 43210 is medically necessary. 

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 an esophagogastroduodenoscopy (EGD) (code 43210) rendered is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: colitis and suspected delirium tremens, erratic behavior, abdominal pain, and diarrhea.
Treatment: Alternate level of care.
The insurer denied coverage for alternate level of care.
The denial is upheld.

The patient is a male with chronic medical problems including hypertension, opioid dependence, and alcohol abuse.  He was admitted to the nursing facility after being hospitalized and treated for colitis and suspected delirium tremens. 

The patient was initially appropriate for the nursing facility care. (1, 2, 3) His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. However, according to the Progress note from the physical medicine and rehabilitation medicine specialist, the patient was "felt to have reached a highest practical functional level in a skilled rehabilitation program at this time and discharged from a skilled rehab program." The treatment notes from his other treating physicians and nursing staff do not support the medical necessity of an alternate level of care. The provider's appeal due to insurance and placement issues does not clinically support the continued stay at the nursing facility. The patient's clinical condition could have been safely monitored as an outpatient or home with home services.  

The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the alternate level of care was not medically necessary.

The insurer's denial of coverage for an alternate level of care is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal seizure.
Treatment is an inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is overturned.

This patient reportedly was admitted to an inpatient medical hospital due to a witnessed alcohol withdrawal seizure and other withdrawal symptoms including an elevated heart rate of 130, nausea, vomiting, tremors, sweats, anxiety, and headache. He reportedly had dilated pupils, salivation from the mouth, tongue numbness, and had a CIWA (Clinical Institute Withdrawal Assessment Alcohol Scale) of 10. He reportedly had elevated CK (creatinine kinase), AP (alkaline phosphatase), ALT (alanine transaminase), glucose, and low Na (sodium). He reportedly was drinking a full bottle of hard liquor or beer daily with a 10-year history of alcohol use. He reportedly was given a Librium taper protocol and prescribed Ativan PRN (as needed) IV (intravenous) and given a banana bag, thiamine, folic acid, and Protonix. He had an EEG (electroencephalogram). An x-ray revealed multiple rib fractures as he reportedly had fallen and hurt his ribs. 

The US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case, this patient had reports of a witnessed alcohol withdrawal seizure as well as other withdrawal symptoms including an elevated heart rate of 130, nausea and vomiting, tremors, sweats, anxiety, headache, and he reportedly had dilated pupils, salivation from the mouth, tongue numbness, and had a CIWA of 10 so he required inpatient medical hospital detoxification treatment then. He was considered at risk for more severe withdrawal, or complicated or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for severe, complicated, and life-threatening withdrawal and in need of 24-hour hospital treatment then. He also had medical issues including elevated CK, AP, ALT, glucose, and low Na.  He did require 24-hour inpatient medical hospital treatment for alcohol and heroin detoxification and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. He was considered a high risk medically and also for relapse if he was not in this 24-hour inpatient hospital setting for detoxification treatment then.

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 inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment is nerve treatment in the spine.
The insurer denied coverage for nerve treatment in the spine.
The denial is upheld.

This patient has chronic low back pain. He has tried NSAIDs (nonsteroidal anti-inflammatory drugs), Tricyclic Antidepressants, Cymbalta, muscle relaxants, Tylenol, and Gabapentin. He has tried PT (physical therapy). He had Epidural Steroid injection. His MRI shows Modic changes at L (lumbar) 3, L4 and L5, and S (sacral) 1. The request is for RFA (Radiofrequency ablation) of the Basivertebral nerves.		

In 2018, Fischgrund and colleagues (1) published a double-blind, sham-controlled RCT (randomized control trial) evaluating the Intracept system and RF (radiofrequency) ablation of the Basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n (number) =78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85C (Celsius) for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100 point scale) and a minimum VAS (visual analog scale) of 4 cm (centimeters) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from the baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13%) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure, and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

Limitations of this study include the lack of sham control and limited duration of follow-up. The publications to date have been company sponsored and had methodology flaws. There is no published data on long-term complication rates.  As per Up to Date "We suggest not using radiofrequency denervation for the management of chronic low back pain. The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short term; however, there does not appear to be a clear long-term benefit. When added to a treatment regimen that includes a regular exercise program and psychologic support, radiofrequency denervation provides little additional benefit."

There are other evidence-based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for nerve treatment in the spine is upheld. Medical Necessity is not substantiated.