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



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

This case involves a man with chronic heart failure who presented to the hospital with ten days of shortness of breath, described as exertional. He also experienced a chest pain episode 1 week before arrival, but no recurrence. He has developed right foot edema but denied recent weight gain. On exam, the patient is described as well-groomed with no distress, normal cardiopulmonary exam, positive peripheral edema, and rales at bilateral bases. The principal admitting diagnosis was acute on chronic systolic heart failure. The patient was started on intravenous (IV) Lasix. Cardiology was consulted, and lisinopril was held due to acute kidney injury on chronic kidney disease. The medical team ordered a renal ultrasound and consulted nephrology.

The Inpatient Hospital Services were medically necessary for this patient.
The patient has known congestive heart failure, with outpatient plans for implantable cardioverter defibrillator (ICD) placement and came into the hospital with exertional dyspnea. She was started on diuretic therapy, and the documentation from 24 hours into the hospital stay states the patient is improved, and the lung exam is documented as clear to auscultation bilaterally. The leg edema improved with diuresis. The secondary problem addressed during the hospital stay was a concern for acute kidney injury, though nephrology clearly states the patient's baseline renal function is unknown. The creatinine remained in the two range throughout the hospital stay. There was no evidence of hydronephrosis causing post-obstructive renal failure. There were no severe electrolyte derangements or signs of uremia. The patient did not have evidence of new hypoxic respiratory failure, hemodynamic instability, anasarca, acute coronary syndrome, or any other end-organ dysfunction to warrant an inpatient level of care. The severity of the illness is mild and can be managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Refractory Multiple Myeloma
Treatment: Oxycontin ER
The insurer denied Oxycontine ER.
The determination is upheld.

This is a male patient with refractory multiple myeloma. The patient is currently taking OxyContin for pain relief. This is under review. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Oxycontin (oxycodone extended release [ER]) or would have adverse effects.

There is a paucity of evidence that the formulary drugs are inferior in any way to the prescribed therapy. Each opioid drug has a different potency, defined as the dose necessary to produce a given effect. When switching from one opioid to another, the starting dose of the new drug can be informed by the difference in their relative potencies to achieve equianalgesic dosing. Neither the National Comprehensive Cancer Network (NCCN) nor the peer-reviewed literature nor the authors of UpToDate consider OxyContin to be superior to the formulary alternatives by any metric. Similarly, evidence of an increased risk of adverse effects is not supported in randomized trials.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Atrovent hydrofluoroalkane (HFA). 
The insurer denied coverage for Atrovent HFA. 
The denial is overturned. 

Patient is a child who was recently hospitalized for viral pneumonia with Metapneumovirus and Rhinovirus infection. The patient has a history of moderate persistent asthma. During the hospitalization the patient had a paradoxical reaction to albuterol so he was treated with Atrovent as a rescue inhaler instead. The child responded well to Atrovent. 

The patient was seen by his primary physician during a follow up office visit, he was complaining of cough at that time. The physical exam was unremarkable. He was prescribed Flovent inhaler, oral steroids and Atrovent as a rescue inhaler.  This patient had not responded to Albuterol in the past. Atrovent was the preferred inhaler for him. 

The alternative bronchodilators which are in the preferred formulary are Spiriva and Yulperi - both of these are long acting maintenance Inhalers and not rescue inhalers. Ipratropium inhaler solution even though a short acting bronchodilator can only be given via nebulization hence not practical for use during emergency bronchodilator needs when patient is at school or outside the home or traveling in-between. Atrovent HFA is the metered dose inhaler and can be carried easily and administered during a need for urgent rescue therapy. 

Based on above Atrovent HFA is the preferred short acting anticholinergic inhaler medication for this patient. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did have an adverse reaction or contraindication to albuterol. 

The formulary drug is expected to be effective but can only be administered through a nebulizer machine which is not practical for emergencies away from home. 

The not formulary drug is expected to be more effective that the formulary alternatives. 

The carrier's denial of Request for Formulary Exception for Atrovent HFA (ipratropium) is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypercholesteremia.

Treatment: Nexletol 180 milligrams (mg) tablet.

The insurer denied coverage for Nexletol 180 mg tablet.

The denial is overturned.

This is a geriatric patient with hypercholesterolemia and bilateral carotid atherosclerotic disease [60% in both right and left internal carotid artery (ICA)] who was prescribed Nexletol.  Past medical history was relevant for hypertension, diabetes mellitus, chronic obstructive pulmonary disease on home oxygen therapy, and coronary artery disease. Current medications include Nexletol 180 mg once daily. On this medication, serum blood testing revealed a total cholesterol 200, high-density lipoprotein (HDL) 38, low-density lipoprotein (LDL) 94 and triglycerides 340 milligrams per deciliter (mg/dl). Prior to treatment, cholesterol panel revealed total cholesterol of 239, HDL 38, LDL 152 and Triglycerides (TG) 246 mg/dl. The patient's cardiologist, the treating provider documents intolerance to statins and Zetia.

This patient could not tolerate multiple statin therapies in doses sufficient to reduce LDL cholesterol below guideline recommended levels (less than 70). Current American Heart Association and American College of Cardiology guidelines clearly note that in patients with Atherosclerotic Cardiovascular Disease (ASCVD) and statin associated muscle symptoms or recurrent muscle symptoms (despite appropriate rechallenge), randomized trial proven non-statin therapy should be considered. (Reference 1) The CLEAR (Cholesterol Lowering via Bempedoic acid, an ACL-inhibiting Regimen) serenity trial was a randomized controlled trial evaluating the efficacy of Nexletol (Bempedoic acid) at the 180 mg dose. Patients with atherosclerotic cardiovascular disease that were intolerant to statin therapy similar to this patient were enrolled in the trial. The results demonstrated a significant reduction in LDL cholesterol (21% reduction) in patients treated with Nexletol. (Reference 2) Additional trials have demonstrated similar results in lowering of LDL-C and the use of Bempedoic acid did not result in an increase in adverse events. (References 3, 4) In conclusion, Nexletol is medically necessary for this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Nexletol 180 milligrams (mg) tablet is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Treatment: Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure 
The insurer denied coverage for Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure 
The denial is overturned.

The patient was diagnosed with achalasia. The patient has had progressive dysphagia. The patient underwent esophageal manometry and had 100% (percent) failed swallows. The manometry findings diagnosed type Ill achalasia. The patient has been advised to have the POEM procedure.

UpToDate has an article titled "Peroral Endoscopic Myotomy (POEM)." The article states that POEM is the endoscopic equivalent of surgical myotomy and a newer technique for the management of achalasla. The POEM procedure can be performed in most patients who have symptomatic, manometry proven primary idiopathic achalasia. It has been shown to be highly efficacious in the short term management of achalasia. A summary of 14 studies of POEM showed a success rate of 82%. Less than 4% required retreatment for achalasia. A subsequent study that involved 117 patients with achalasia undergoing the POEM procedure and were followed for 545 days found a success rate of 91%. It was found to be equally successful as compared to a surgical myotomy in controlling symptoms at the 2 year point. The article states that based on current literature, patients with achalasia should be informed that POEM and a Heller myotomy are equally effective in relieving dysphagia.

The scientific literature supports the use of the POEM procedure in improving health outcomes. The POEM procedure has been approved by the Food and Drug Administration (FDA). The patient Is a good candidate since the patient has increasing symptoms of dysphagia from achalasia and has a diagnosis of achalasia that was confirmed by manometry. There are alternative treatments for achalasia but the POEM procedure has been shown to be effective and safe. The POEM procedure is less invasive than a surgical myotomy and is therefore likely to be more beneficial for the patient.

The denial is overturned.

In summary, the denial of Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Treatment: Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure 
The insurer denied coverage for Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure 
The denial is overturned.

Achalasia is an esophageal motility disorder with an unknown etiology. Balloon dilation, botulinum toxin injection and Heller myotomy have been used as treatment options. Surgical/Heller myotomy has been known as the definitive treatment option. Peroral endoscopic myotomy (POEM) is an additional option. It has been shown to be safe, less invasive, and offers long-lasting symptom management. It can also be used as a second-line treatment in those who have failed Heller myotomy. Studies have shown that POEM led to improvements in lower esophageal sphincter pressures at 2 months, one year, and three years after intervention. POEM has been shown to be equally effective as laparoscopic Heller myotomy in the treatment of achalasia. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has recommended POEM over Heller myotomy for achalasia subtype III. Type I and II achalasia may be treated with either POEM or Heller myotomy depending on surgeon and/or patient preference.

Per the provided documentation, the patient was evaluated for difficulty swallowing. The patient also has a history of celiac disease. The patient reported progressive difficulty in swallowing solid foods. The patient felt as if food was getting stuck in the chest. There was no regurgitation or vomiting of food. An upper Gastrointestinal endoscopy did not demonstrate any areas of obstruction. The patient had a manometry study with findings consistent with type II achalasia: integral relaxation pressure of 35.7, 100% (percent) failed swallows with 80% pan esophageal pressurization with no premature contractions. The patient is an appropriate candidate for the procedure. POEM devices have Food and Drug Administration (FDA) approval. In this patient with type III achalasia, this service is likely to be more beneficial than any of the standard treatments.

In summary, the denial of Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee genu varum

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

 
This is an adult with a history of severe left knee genu varum and morbid obesity. The patient presented to the hospital for a scheduled left high tibial osteotomy, mid fibula osteotomy, and application of multiplanar ring external fixation device. The procedure was performed, and the patient was admitted for postoperative care. The patient was given intravenous (IV) hydromorphone, IV fluids, IV Cefazolin, IV ketorolac, and oxycodone. The patient received physical therapy and occupational therapy (PT & OT). The surgical site was assessed. The patient was discharged. 

The medical records show a complex and extensive reconstructive procedure was performed. The duration of anesthesia was over 4 hours. The American Society of Anesthesiology (ASA) level was 3. There was documentation of morbid obesity.

The post surgical course showed problems with ambulation and pain levels. An osteotomy requires breaking the tibia and fibula. It is painful and patient-controlled analgesia (PCA) was required after the operation.

There would be great difficulty in mobilizing this person considering weight and presence of an external fixator.

The level of services would not be appropriate at a lower level of care.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Social Anxiety Disorder F40.10
Treatment: Consumer Directed Personal Assistance Service for 56 Hours Per Week
The insurer denied: Consumer Directed Personal Assistance Service for 56 Hours Per Week
The denial is partially overturned.

This case involves an adult male diagnosed with social anxiety disorder associated with substantial impairments in functioning including basic and instrumental activities of daily living. The patient is requiring five to six hours of personal care assistance for meal preparation, shopping, medication administration, and his CPAP (continuous positive airway pressure) device. Additionally, the patient requires accompaniment to appointments and assistance with instrumental activities in order to maintain his home environment. Additionally, the patient's mother, with whom he lived, passed away last year which has compounded the patient's living situation. The patient's brother has stepped in to assist the patient accordingly. The requested personal care assistance services with up to 56 hours per week has been denied coverage based on medical necessity. The denial determination indicates that current allotment of five hours is sufficient for the patient's needs.

The appeal is based on the patient's functional impairments indicating that the patient needs five to six hours per day or 35 hours per week of personal assistance, and the initial request for 56 hours per week is not needed. 

The proposed treatment of the requested health service/treatment of Personal Care Assistance Services with up to 35 hours per week is medically necessary for this patient. 

The submitted documentation together with the case summary and other materials including the caregiver statement, clearly indicate the need for the personal care assistance, as requested. The patient's psychiatric condition together with functional impairments do require the level of assistance that has been requested in this case scenario. There is documented evidence that the patient's functioning and the psychiatric conditions have improved but may have worsened with the death of his mother. Thus, the requested benefit of Personal Care Assistance Services is medically necessary for this patient with up to five to six hours per day and 35 hours per week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Positional dizziness and right leg gait instability.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This elderly male with a history of diabetes, gout, hypertension, and alcohol withdrawal presented complaining of one week of positional dizziness and right leg gait instability. Symptoms are associated with a productive cough and 40-pound unintentional weight loss. Vital signs stable and afebrile. Exam was unremarkable. Labs were unremarkable. Orthostatic was negative. EKG (electrocardiogram) was completed with normal sinus rhythm. Chest x-ray results were noted with no acute disease. The knee x-ray showed osteoarthritis. Head CT (computed tomography) was performed with no acute disease. 
The patient was admitted. Plan of care included antibiotics. On the next day, neurology was consulted for vertigo. Home meclizine was restarted. Plan was for additional imaging. Sputum was sent for TB (tuberculosis). Prednisone was started for possible gouty flare. On Day #3, plan was to follow up on imaging. On Day #4, orthopedics was consulted for knee pain. Plan was to follow up imaging. On Day #5, imaging from the day before was unremarkable. On Day #6, AFB (acid-fast bacilli) samples were negative times three (3). On Day #7, the patient was stable for discharge with outpatient orthopedics follow up. 

The proposed treatment is not medically necessary. 

This patient was admitted after presenting with symptoms consistent with vertigo associated with cough and weight loss, and knee pain. He was hemodynamically stable and afebrile. Imaging and labs were unremarkable for an acute condition. Antibiotics were started and his home medications were resumed. During hospital stay, he had cultures for TB (tuberculosis) and was being evaluated for knee pain. He had not failed a lesser level of care. The intervention provided did not require an acute inpatient level of care. Inpatient Hospital 
Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mesenteric mass
Treatment: CT guided biopsy of mesenteric mass, procedure code 49180) in a hospital setting
The insurer denied coverage for CT guided biopsy of mesenteric mass, procedure code 49180) in a hospital setting
The denial is overturned

There is a 7 centimeter (cm) mesenteric mass in the left hemiabdomen. A computed tomography (CT)-guided biopsy of the mesenteric mass, procedure code 49180, was performed in the hospital setting. Follicular lymphoma was diagnosed.

Documentation does not appear to support that this patient was admitted to the hospital. The procedure was performed in the hospital as an outpatient. The insurer did not provide data supporting the availability of a non-hospital setting facility that can provide the procedure.    

The procedure (CT guided biopsy of mesenteric mass, procedure code 49180) in a hospital setting is considered medically necessary for this patient. As far as the records show, there was no admission to the hospital, and the claimant spent only a few hours in the facility to be sedated and then observed after the procedure. Functionally, this is equivalent to an outpatient free-standing center performing the same procedure. 

"We included 225 procedures performed in 212 patients, of whom 143 (63.5%) had a prior diagnosis of cancer. Of the 225 lesions biopsied, 88 (39.1%) had a suspected primary origin and 137 (60.9%) were suspected metastatic lesions. Complications occurred in only 14 (6.2%), the most common being self-limited bleeding, which occurred in 12 (85.7%) of the 14. The occurrence of complications was not found to be significantly associated with the lesion location, age of the patient, presence of comorbidities, use of a supplementary technique, vascularization pattern, or proximity of the lesion to large vessels. The pathology findings were sufficient for making the diagnosis in 202 cases (89.8%), and the diagnosis was consistent with the clinical suspicion in 132 (58.6%). Conclusion: The procedure demonstrated a high (approximately 90%) rate of providing a sufficient sample for the diagnosis and a low complication rate, the most common complication being self-limiting bleeding." (Shiavon et al., 2018)

"Surgical or imaging-guided percutaneous biopsy is an extremely important part of the diagnosis, staging, and follow-up of suspected or known malignancies. In the past, surgical biopsy procedures were necessary in order to obtain sufficient samples of the lesion for the appropriate pathological diagnosis." (Nunes, 2018)     

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for procedure (CT guided biopsy of mesenteric mass, procedure code 49180) in a hospital setting is substantiated.