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

Diagnosis: lumbar pain

Treatment: medial branch block

The insurer is denied coverage for medial branch block

The denial is overturned. 

This male patient has a history of lumbar spondylosis and facet arthrosis. The patient is status post two level fusion, L4/5, and L5/S1. The patient reports over 80% initial relief of right sided pain and 50% initial pain relief for approximately 3 month with less stiffness and improvement in sitting for 30 minutes at a time, prior to procedure the patient was only able to tolerate 10 minutes in one position.  The patient is following up with worsening right sided lumbar pain.  The patient states that the pain is constant, severe, worsening with lumbar extension and rotation. An magnetic resonance imaging (MRI) was of the lumbar spine was significant for facet arthrosis.

Manchikanti et al. (1) published evidence-based guidelines for facet blocks and reviewed "the criterion standard of 80% pain relief was utilized in 4 studies in 1,802 patients that showed a prevalence ranging from 27% to 40% in a heterogenous population. All the patients assessed with 80% pain relief criterion standard were by Manchikanti and colleagues in prior studies. They utilized the standard of chronic pain with relief lasting beyond pharmacological duration of action of the local anesthetic for both lidocaine and bupivacaine. Further, Manchikanti et al. also utilized lidocaine the short-acting local anesthetic initially followed by bupivacaine the longer-acting anesthetic in all the studies. 
	
The evidence for accuracy of lumbar facet joint nerve blocks is Level I to II based on 10 diagnostic accuracy studies with 4 studies utilizing greater than or equal to 80% criterion standard of pain relief with a prevalence rate of 27% to 40% with false-positive rates of 27% to 47%."

Similarly, Cohen et al (2) produced a consensus guideline in which they "conclude that MBB [medial branch block] should be the prognostic screening test of choice before lumbar facet RFA[radiofrequency ablation]."

The patient achieved 80% pain relief on the right side. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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

The carrier's denial of coverage for the medial branch block  is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient admission. 

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

The patient is a G2P2 (two pregnancies, two births) with a history of abnormal uterine bleeding. She presented to the ED (emergency department) with heavy vaginal bleeding.  She had just been seen in the ED (emergency department) the day prior and evaluated and discharged.  Overnight, she reported that she changed her pad eight times.  She became dizzy, and the bleeding had not stopped, so she returned. 

The patient was evaluated with blood work, which revealed a hemoglobin of 5.9.  She was given IV (intravenous) and fluids.  She was given a blood transfusion with two units of packed red blood cells. After the completion of the transfusion, she had stable blood pressure, but became tachycardic from 100-110 with some back pain, so she was admitted. 

The patient was given one additional unit of blood, as well as tranexamic acid 1300mg (milligrams) TID (three times daily).  Her vitals were stable.  She was having minimal bleeding.  The plan was for a hysterectomy as an outpatient in a few days' time.  She was stable with increase in hemoglobin to 8.6.  She was discharged home on tranexamic acid for five days and provera twice daily.  Follow up was arranged. 

No, the Inpatient admission was not medically necessary. 

The patient presented with acute blood loss anemia.  She was hemodynamically stable except mild tachycardia.  Admission to inpatient level of care was not the most conservative service available to provide safe and effective care.  The patient required continued monitoring however the same care could have been provided at a lower level of care.  This would have provided the same safety and outcome. Therefore, the inpatient admission was not medically necessary. 

Medical necessity means services or supplies that a health care provider, exercising prudent clinical judgement, renders to or recommends for, a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms.  These health care services are in accordance with generally accepted standards of medical practice, clinically appropriate, in terms of type frequency, extent, site and duration, and considered effective for the patient's illness, injury, or disease, not primarily for the convenience of the patient or health care provider and not more intensive than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results in the diagnosis or treatment of the patient's illness, injury or disease. 

Because a lower level of care would have been just as likely to produce equivalent outcome, the health plan acted reasonably to deny the inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leiomyosarcoma
Treatment: PET (positron emission tomography) scan.

The insurer denied a PET scan. The health plan's determination is upheld. 

This is a female with recurrent leiomyosarcoma. The patient has previously undergone radiation and surgery. The patient had difficulty tolerating chemotherapy and declined it at relapse. She has intermittent abdominal and left rib pain. The patient has had a positron emission tomography (PET) / computed tomography (CT) that demonstrated osseous metastatic disease in the left mid-sacrum. A PET scan has been requested for routine restating and is under review.

The PET scan is not medically necessary.

This patient is asymptomatic and is at baseline per the included documentation. The patient is eating, weight is improved, and she has no significant toxicities beyond pain that has also improved since her prior visit. In this setting, imaging is being obtained for routine restating. In this setting, the role of PET is unclear. The use of this modality has not been demonstrated to improve outcomes and it is not recommended by the peer-reviewed literature, the National Comprehensive Cancer Network (NCCN), nor by the authors of UpToDate.

The authors of UpToDate sate "...There is no evidence that PET provides more useful information than either computed tomography (CT) or magnetic resonance imaging (MRI)...." Lacking supporting data and guideline recommendations, medical necessity for the PET scan cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain.
Treatment: Capsule Endoscopy.
The insurer denied a Capsule Endoscopy. 
The health plan's determination is overturned. 

The patient is a female. She has had nausea, intermittent cyclical vomiting, abdominal pain, diarrhea with electrolyte abnormalities (including low potassium of 2.1 mmol/L -millimoles per liter- ) resulting in muscle spasms, and malnutrition. She was admitted to the hospital recently. Computed tomography scan of the abdomen and pelvis showed short-segment small bowel intussusception in the left mid-abdomen of uncertain etiology and no visible leading mass. Gastroenterology consultation noted that intussusception was suspected to be in mid-jejunum beyond the reach of push enteroscopy. Esophagogastroduodenoscopy showed Los Angeles grade A distal reflux esophagitis, normal stomach, normal duodenum. Colonoscopy showed a diminutive rectal polyp (removed) and otherwise normal terminal ileum, colon, and rectum. Gastric emptying study was somewhat delayed at 2 hours, but normal at 4 hours. Patency capsule test did not show retention.

A capsule endoscopy is medically necessary in this case.

Wireless capsule endoscopy has shown effectiveness for localization of small bowel tumors. Gastrointestinal carcinoids often present in the small bowel, where this patient had intussusception of the bowel on computed tomography scan. Wireless capsule endoscopy has a comparable diagnostic yield to nuclear imaging with superior differentiation between intestinal and mesenteric lesions, and can find lesions not seen on upper endoscopy (which only reaches the proximal small intestine) or colonoscopy (which only reaches the distal small intestine). Capsule endoscopy is reported as having high sensitivity in identifying small-bowel tumors. The most recent American Society for Gastrointestinal Endoscopy guidelines for appropriate use of endoscopy recommend capsule endoscopy for diagnosis of suspected small intestinal tumors, which are suspected in this case given the suspected jejunal intussusception on computed tomography scan. As esophagogastroduodenoscopy and colonoscopy have not been sufficient to evaluate the region of intussusception in the small bowel, wireless capsule endoscopy is supported as medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia due to multiple transient ischemic attacks; and gait abnormality. 

Treatment: Personal Care Worker (PCW) Services of 7 days per week, 24 hours, live in. 

The insurer denied coverage for Personal Care Worker (PCW) Services of 7 days per week, 24 hours, live in. 

The denial is overturned. 

This is a female patient with a past medical history of hypothyroidism, asthma, dyslipidemia, hypertension, dementia due to multiple transient ischemic attacks and episodes of slurred speech, chronic obstructive pulmonary disease, Vitamin B12 deficiency anemia, compression deformity of the cervical spine, multiple falls due to gait abnormality, a cerebral aneurysm and sigmoid cancer with status post resection. 

The patient was admitted to the hospital for diagnoses of an elevated sedimentation rate, observed seizure like activity and slurred speech.  She was eventually transferred to a rehabilitation facility.  She was discharged from the rehabilitation facility and an increase to personal care worker (PCW) services of 7 days per week, 24 hours, live-in is being requested.

Uniform Assessment System (UAS) documentation notes that the patient needs extensive assistance with transfers, walking and toileting.  Notes from the sub-acute rehab (SAR) note the same.  The insurer has noted minimal help is needed for these functions.  The patient is incontinent of urine and needs scheduled daytime bathrooms visits; they are as needed at night.  Given her degree of impairment and the toileting needs she would meet the above criteria for an aide 24 hours/day, 7 days/week.  There is a reasonable expectation an aide could get uninterrupted 5 hours of sleep. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The plan did not use up-to-date assessments of the patient's functional status. 

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 7 days per week, 24 hours, live in is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Diabetes Mellitus,
Dementia and Depression
Treatment: Increase Personal Care Worker (PCW) Service from 7 Days per Week, 4.5 Hours per Day, 31.5 Hours per Week TO 7 Days per Week, 8 Hours per Day, 56 Hours per Week
The insurer denied the Increase Personal Care Worker (PCW) Service from 7 Days per Week, 4.5 Hours per Day, 31.5 Hours per Week TO 7 Days per Week, 8 Hours per Day, 56 Hours per Week.
The denial is overturned. 

The patient is a male with a history of Coronary Artery Disease, Diabetes Mellitus, Dementia and Depression. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours per week Personal Care Worker service to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 56 hours per week Personal Care Worker service is deemed medically necessary.

Recent correspondence from the patient's medical provider indicates that due to progressively worsening cognitive and functional decline secondary to the patient's progressively worsening dementia and Parkinsonism, the patient now requires assistance with all activities of daily living and instrumental activities of daily living. For these reasons, the currently approved plan of 31.5 hours per week Personal Care Worker service is insufficient to meet the patient's current needs. Hence, the proposed treatment of 56 hours per week Personal Care Worker service is deemed medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Migraine. 
Treatment: Pharmacy/Prescription Drugs-Ubrelvy (ubrogepant).
The insurer denied Ubrelvy (ubrogepant) as formulary medications were not trialed and failed. 
The denial has been upheld in whole.

The patient is a female with a past medical history of hypertension, hyperlipidemia, myocardial infarction, coronary artery disease and chronic migraine. Treatment with Ubrelvy has been prescribed. The member cannot use triptan medications due to cardiac disease.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
The health plan's determination is upheld in whole.

The patient has a history of myocardial infarction and coronary artery disease. The formulary alternatives include triptan medications, including almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan injection, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, Zembrace Symtouch, and Zomig nasal spray. These drugs are a contraindication in patients with a history of myocardial infarction, poorly controlled hypertension, and coronary artery disease. As such, these alternatives would have adverse effects.
The provider states that the claimant is unable to take Nurtec orally disintegrating tablets (ODT) due to "potential drug interaction with some of her cardiac medications." There is no rationale provided. As such, it is not explained which medications Nurtec would interact with and what side effects are possible. Neither Ubrelvy nor Nurtec ODT should be used with strong Cytochrome P450 3A4 (CYP3A4) inducers. Thus, the potential interaction would apply to both drugs. 
As such, Ubrelvy is not medically necessary over Nurtec ODT as there is no specific reason provided as to what adverse effects would occur and the drugs have similar efficacy for treatment of acute migraine.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: anterior crossbite.
Treatment: braces/monthly visits.
The insurer denied Braces and Monthly Visit x 12. 
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 11. She presents with a skeletal Class I malocclusion with crowding in the maxilla and mandible. She is treatment planned for 18-24 months of orthodontics to address the crowding and crossbite.

Braces and Monthly Visit x 12 are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 11, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. She is already starting to develop recession as 22 moves labially in the arch. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Varicose Veins
Treatment: Surgical Services-Ambulatory Phlebectomy
The plan denied the Vein Procedure as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient presented with right leg symptomatic varicose veins. Her main symptoms include right leg phlebitis. She underwent prior left saphenous vein ablation. She has attempted and failed conservative therapy with graded compression stockings without symptomatic relief. She is noted to have refluxing varicose veins on the right on duplex ultrasound. The provider is recommending right leg ambulatory phlebectomies for treatment of her condition. (current procedural terminology (CPT) 37765, 37766, 37785 and 37799). Only one of the aforementioned CPT codes will be billed, but all are being submitted for preauthorization.

Right leg stab phlebectomy is Medically Necessary based on the peer reviewed literature and the current standard of care in the vascular surgery community.
Ambulatory phlebectomy is a well-established and current treatment for symptomatic varicose vein tributary veins. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support ambulatory phlebectomy for the treatment of symptomatic varicose veins when the patient's saphenous vein reflux has been treated either in staged or concomitant fashion. There are several current peer reviewed studies which support the use of concomitant stab phlebectomy in patients being treated with thermal ablation for symptomatic varicose veins. The reason why several CPT codes are typically preauthorized (37799, 37785, 37765, 37766) is because the provider is unsure regarding the number of ambulatory phlebectomies required until the time of the surgery. Each individual CPT code corresponds to a different number of phlebectomies performed. The provider will be billing one of those codes. This is medically necessary and consistent with the current standard of care in the vascular surgery community for this patient.
Appeal type: Formulary Exception
Decision: Overturned


Diagnosis: herpes vesicular dermatitis.
Treatment: Acyclovir cream.
The insurer denied the Acyclovir cream as formulary medications were not trialed and failed. 
The reviewer has overturned in whole the health plan's determination. 

The patient is pregnant.  Acyclovir cream was prescribed for herpes vesicular dermatitis. This was denied by the health plan as formulary drugs including acyclovir oral, famciclovir, and valacyclovir were not tried/failed. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Yes, the formulary drug would have adverse effects.  According to the records from the patient's provider, the patient is pregnant.  The pregnancy category for all 3 oral formulary agents acyclovir, famciclovir, and valacyclovir is "Fetal risk cannot be ruled out," according to pharmacy compendia.  The requested non-formulary drug is less likely to cause adverse effects, given that the patient is documented as being pregnant, than formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Radiology Services (including Ultrasound).  
The insurer denied Computed Tomography (CT) of Abdomen and Pelvis with and without Contrast (Dye). 
The denial was upheld in whole. 

The patient is a female, who had been trying to conceive without success. She had a prior history of left nephrectomy due to malpositioned left kidney. The patient felt that she had a septate uterus and was referred to a reproductive endocrinologist for evaluation. The patient was reported to have a possible septate or bicornuate uterus by pelvic ultrasound and was recommended for a pelvic magnetic resonance imaging (MRI) scan for determination of the uterine anatomy. The MRI was completed and determined the uterus had no septation, but was noted to suggest an arcuate uterus. The patient was then ordered to undergo a computed tomography (CT) scan of the abdomen and pelvis to clarify the findings. 

At issue for medical necessity is the Computed Tomography (CT) of Abdomen and Pelvis with and without Contrast (Dye).

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

The requested health service/treatment of CT of abdomen and pelvis with and without contrast (dye) is not medically necessary for this patient.

The requested health service/treatment of CT of the abdomen and pelvis with and without contrast (dye) would not be medically necessary, given the patient had already undergone an ultrasound and confirmatory MRI that had excluded a septate or bicornuate uterus. The findings on MRI were that of an arcuate uterus, which is not associated with infertility and would not carry adverse risk for pregnancy or management for fertility therapies. The standard for diagnosis is ultrasound and, in this case, the ultrasound was not confirmatory. Thus, the standard for advanced imaging is an MRI scan. A CT scan would not be a modality recommended for evaluation of the uterus for uterine malformation and would not add additional information or accuracy to the MRI finding.

In this case, the patient had undergone definitive imaging of the pelvis by ultrasound and MRI and would not have had medical necessity for a CT scan of the abdomen and pelvis with and without contrast (dye), given this is not recommended by American College of Obstetricians and Gynecologists (ACOG). 

Therefore, the Computed tomography (CT) of abdomen and pelvis with and without contrast (dye) is not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypothyroidism.
Treatment: Formulary exception for Tirosint 75 MCG Capsule, Pre-service.
The insurer denied the Formulary exception for Tirosint 75 MCG Capsule, Pre-service.
The denial is upheld. 

The patient is a female diagnosed with Postprocedural Hypothyroidism. This request is for Tirosint. As reported, she tried and failed Synthroid, levothyroxine Sodium and Levoxyl. Her thyroid levels have been well-managed while being on Tirosint. 

No, the health plan should not cover the formulary exception for Tirosint.

The available records report failure of Synthroid, levothyroxine, Levoxyl. However, there is no documentation of why the patient failed, how the patient was treated, and whether the TSH (thyroid stimulating hormone) became erratic or elevated. Given the absence of clear records showing how the patient failed these medications, there is no reason why the patient would be expected to fail the remaining formulary alternatives. The patient can try the remaining formulary alternatives. The health plan should not cover the requested formulary exception.