Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroparesis

Treatment: Peroral Endoscopic Myotomy [POEM] procedure; code 43999 (usual procedure of the stomach) x (times) 1

The insurer denied coverage for the POEM procedure; code 43999 x 1.

The denial is overturned.

According to the documentation submitted, this is the case of an adult female with a history of multiple sclerosis and gastroparesis. The patient was seen by her doctor and noted the patient was taking erythromycin as well as omeprazole for gastroparesis. The plan was for further studies.

There is scientific evidence in peer reviewed literature to support and substantiate its improvement in health outcomes as well as its safety and effectiveness. However, the long-term results have not been documented and the studies are limited in case volume.  

Khashab noted in UpToDate that several case reports show that Gastric Peroral Endoscopic Myotomy G-POEM is safe, feasible, and effective in treating severe refractory gastroparesis.  

This procedure is Food and Drug Administration (FDA) approved.

This patient is a candidate for this treatment given the documentation of gastroparesis. As noted by Khashab noted in "Peroral endoscopic myotomy (POEM)" UpToDate: 2021 POEM for gastroparesis - "Initial management of gastroparesis consists of dietary modification, optimization of glycemic control and hydration, and pharmacologic therapy with prokinetic and antiemetic medications. Patients who are refractory to medical therapy may require surgical interventions in the forms of tube gastrostomy, subtotal gastrectomy, or pyloroplasty. Surgical pyloroplasty (e.g., Heineke-Mikulicz pyloroplasty) can lead to sustained improvement of symptoms in patients with refractory gastroparesis. Gastric peroral endoscopic myotomy (G-POEM), which is an endoscopic equivalent of surgical pyloroplasty, has been performed in a few centers for severe refractory diabetic gastroparesis."

It is true that the patient has gastroparesis and therefore requires treatment. It is also true that this procedure is less invasive that surgical treatment such as surgical pyloroplasty. The adverse risks are not increased over standard treatment services as this procedure is less invasive than the surgical pyloroplasty.

This reviewer disagrees with the insurer that in this case although the G-POEM may not have sufficient studies to document long term success, given the alternatives it is reasonable for the patient to undergo this procedure. The procedure may be more likely to be more beneficial to this patient than an invasive surgical procedure. Furthermore, it should be understood that the insurer denied this procedure on the basis of using POEM in a patient with achalasia. This patient does not have achalasia -she has gastroparesis of the stomach. Therefore, based upon the clinical information provided the POEM is justified.  

The carrier's denial of the POEM procedure; code 43999 x 1 should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroparesis

Treatment: Peroral Endoscopic Myotomy [POEM] procedure; code 43999 (usual procedure of the stomach) x (times) 1

The insurer denied coverage for the POEM procedure; code 43999 x 1.

The denial is overturned.

The patient has multiple sclerosis and gastroparesis. She has failed multiple medications. A gastric emptying study was consistent with gastroparesis. A computed axial tomography (CAT) Man also showed delayed gastric emptying. She has now been referred for Gastric Peroral Endoscopic Myotomy (G-POEM).

Up-to Date has an article titled "Peroral Endoscopic Myotomy (POEM)". The article discusses POEM for gastroparesis. Multiple studies were reviewed. A significant improvement in the Gastroparesis Cardinal Symptom Index Score was found. 78% (percent) had better gastric emptying scores. Adverse effects were encountered only 1n a small number of patients, most of which were mild and conservatively managed.

The scientific literature supports the use of G-POEM, and it has resulted in improved patient outcomes. The POEM procedure has been approved by the Food and Drug Administration (FDA). The patient is a good candidate because she did poorly with medical therapy for gastroparesis. There are multiple treatments for gastroparesis, but this procedure has been shown to be effective in patients who failed medical therapy. The adverse effects of the procedure are usually mild and managed conservatively. It is likely that this procedure would be more beneficial for this patient as compared to continuing with medical therapy that has already not been successful.

The carrier's denial of the POEM procedure; code 43999 x 1 should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, type 2 diabetes mellitus, osteoarthritis, unsteady gait, late onset Alzheimer's disease

Treatment: personal care aide (PCA), 12 hours per day, 7 days per week, for a total of 84 hours per week

The insurer denied coverage for personal care aide (PCA), 12 hours per day, 7 days per week, for a total of 84 hours per week.

The denial is overturned.

The patient has a history of hypertension, type 2 diabetes mellitus, osteoarthritis, unsteady gait, late onset Alzheimer's disease and frailty. The Visiting Doctors House Call notes the patient has had multiple falls and cervical disc herniation. The daughter reported the patient had increased debility and difficulty getting to the clinic. There is caregiver stress. The patient is noted to be able to ambulate within the apartment but goes out in a wheelchair. Uniform Assessment System (UAS) notes that she needs maximal assistance/is dependent for activities of daily living (ADLs). She is occasionally incontinent. An increase in personal care aide (PCA) services from 8 hours per day, 7 days per week to 12 hours per day, 7 days per week is requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The reviewer disagrees with their decision. 

The patient has impairments as noted above. The physician documents that she is worsening. Her daughter provides nighttime coverage but has a full-time job. The patient needs assistance for all functions, and safety is part of the provision of those services.  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 personal care aide (PCA), 12 hours per day, 7 days per week, for a total of 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid myopathy with rheumatoid arthritis, chronic pain, wheelchair bound, dermatitis, elbow arthritis, gastroesophageal reflux disease with esophagitis, iron deficiency anemia, joint pain and obstructive sleep apnea 
Treatment: Increase Personal Care Services (PCS) to 24 Hours Per Day; 7 Days Per Week (split shift) For A Total of 168 Hours
The insurer denied the Increase Personal Care Services (PCS) to 24 Hours Per Day; 7 Days Per Week (split shift) For A Total of 168 Hours.
The denial is upheld. 

The patient is a female. The appeal is regarding denial of increase Personal Care Services (PCS) to 24 hours per day, 7 days per week, split shift.  The plan approved 91 hours/week, live-in.

UAS (Uniform Assessment System) evaluation completed showed the patient needs assistance with meal preparation, housekeeping, laundry, shopping, hygiene, dressing, eating and bathing.  The patient moves around in wheelchair with assistance.  She needs assistance with transfers.  She does not have incontinence.

No, the Increase in Personal Care Services (PCS) to 24 Hours Per Day; 7 Days Per Week (split shift) for a total of 168 Hours/week is not medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.  This patient has been approved 91 hours/week, live-in.  The appeal is regarding denial of increase Personal Care Services (PCS) to 24 hours per day, 7 days per week, split shift.

The patient's UAS (Uniform Assessment System) evaluation showed the patient needs assistance with meal preparation, housekeeping, laundry, shopping, hygiene, dressing, eating and bathing. She does not have incontinence.  There no documentation that the patient has continuous needs, such as frequent turning/repositioning, that would prohibit an aid from getting five hours daily of uninterrupted sleep during the aide's shift.  Therefore, the proposed increase PCS (personal care service) to 24 hours per day, 7 days per week, split shift is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Pain Syndrome
Treatment: 63650 - Percutaneous Implantation of Neurostimulator, Pre-service
The insurer denied the  63650 - Percutaneous Implantation of Neurostimulator, Pre-service.
The denial is upheld. 

The patient is a female. The patient has history of neck and lower back pain with bilateral lower extremity pain. 10/10 pain score. Pain impacts all aspects of her life. She completed a home exercise regimen, tried epidural steroid injections, cervical facet blocks, sacroiliac injections, kyphoplasty. The patient has also tried Motrin, morphine, Neurontin. The patient is not a surgical candidate. This is a request for SCS (spinal cord stimulator) trial.

No, the requested 63650 - Percutaneous Implantation of Neurostimulator is not medically necessary.
The patient does not have history of back surgery or trauma-related nerve root injury. She also does not have diagnosis of CRPS (complex regional pain syndrome), or arachnoiditis.

Per AIM guideline Spinal Cord Stimulators, stimulator trial may be indicated when all of the following criteria are met: The patient has chronic intractable neuropathic pain of the trunk and/or limbs associated with at least one of the following conditions: Lumbosacral arachnoiditis as documented by high levels of protein in the cerebrospinal fluid and/or imaging (MRI [magnetic resonance imaging] or myelography), Nerve root injuries that are post-surgical or post-traumatic, including post-laminectomy syndrome (failed back syndrome), Complex regional pain syndrome (CRPS), type I or type II (formerly known as reflex sympathetic dystrophy or causalgia).

SCS (spinal cord stimulator) was mostly studied for lumbar failed back syndromes, and there is ample literature supporting its use for lumbar post laminectomy pain syndromes.  There is little literature to support SCS (spinal cord stimulator) application for chronic low back pain without undergoing spine surgery.

As per one of the articles as listed below, despite the magnitude and long-term quality of the improvements observed, a randomized controlled trial, preferably using an active placebo control, remains necessary to clearly support the effect of 10-kHz (kilohertz) high-frequency SCS (spinal cord stimulator) in this category of patients. This challenges the established view that SCS (spinal cord stimulator) is effective mainly for radicular pain caused by spine surgery. SCS (spinal cord stimulator) has never been recommended to treat axial low back pain, as it can be technically difficult to stimulate back pain pathways. If further appropriately designed RCT (randomized controlled trial) studies verify that 10-kHz high-frequency SCS (spinal cord stimulator) is effective for treating low back pain, this will create entirely new therapeutic opportunities.

The submitted documentation and records do not support that the patient meets the criteria for the procedure. Therefore, the 63650 - Percutaneous Implantation of Neurostimulator is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia

Treatment: Personal Care Worker (PCW) services of 7 days per week, 24 hours per day, live in; 91 hours per week

The insurer is denied coverage for PCW services of 7 days per week, 24 hours per day, live in; 91 hours per week.

The denial is overturned. 

This female patient has a history of Alzheimer's dementia with paranoia, anxiety, depression, coronary heart disease, diabetes mellitus, chronic back pain and left lower extremity edema.  

The patient needs extensive assistance with all activities of daily living (ADLs) except limited for bed mobility. She is incontinent. She has problems using her arms and hands (extensive assistance needed for dressing). She has cognitive impairment. 

The provision of diapers and durable medical equipment (DME) is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary. (6) She may have the physical ability to wander but she does not have the cognitive and physical functional capacity to reliably manage her own DME and toileting. She is subject to unscheduled nighttime needs, beyond the scope of 8 hours/day coverage. The patient request is approved.

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 PCW services of 7 days per week, 24 hours per day, live in; 91 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient has a history of eczema and presented with a five-day history of painful swelling around her right areola. There was no history of fever, and no history of abscesses in the past. Labs were unremarkable, including a normal complete blood count (CBC), except for elevated C-reactive protein (CRP). On examination there was an 8 by 8-centimeter area of induration of the right breast around the nipple and areola, with overlying erythematous skin, warm and mildly tender, with no fluctuance. The ultrasound study did not show any evidence of abscess, only an inflammatory process and reactive nodes. The emergency room (ER) physician medical decision-making note does not present adequate clinical justification for admission to inpatient level of care. The diagnosis was cellulitis, the portal of entry being the skin because of pruritus secondary to the eczema. Clinically there was no reason to suspect necrotizing fasciitis either. She did not fulfill Systemic Inflammatory Response Syndrome (SIRS) criteria and did not look sick or toxic. The evidence for lack of need for parenteral therapy is detailed in the review articles/guidelines cited below.

The patient could have been discharged from observation with an ambulatory plan of care. Clindamycin could have been administered safely as an outpatient by the oral route following the initial parenteral dose received in the emergency room.

The inpatient admission is not considered medically necessary for this patient. The health plan acted reasonably, with sound medical judgement, and in the best interest of the patient.

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

Diagnosis: Duodenitis

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is upheld.

This is a patient with end stage renal disease status post transplant admitted for chronic gastrointestinal (GI) symptoms. She underwent upper endoscopy, which showed duodenitis and was started on proton pump inhibitor (PPI). She was also evaluated by infectious diseases (ID) for possible bacteremia but then considered contamination and she was discharged.

The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function needing renal replacement therapy, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain.

Observation level of care is appropriate when oral replacement therapy is feasible for individuals with mild or moderate dehydration who can drink and have no significant dehydration-related cognitive or physical compromise.

A randomized study of 13,347 non-critically ill adults requiring intravenous (IV) fluid treatment in the emergency department randomized to treatment with isotonic crystalloid or normal saline found no difference in hospital-free days but found that patients treated with the isotonic crystalloids had a lower composite outcome of death, need for renal-replacement therapy, or persistent renal dysfunction than the saline-treated group.

There is no evidence-based literature supporting that inpatient level of care was medically necessary. Her condition could have been treated safely under lower level of care.

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

Based on the above, the medical necessity for the inpatient stay is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain. 
Treatment: Epidural Steroid Injection. 

The insurer denied the Epidural Steroid Injection. 
The health plan's determination is overturned. 

This is a female diagnosed with low back pain and lumbosacral radiculopathy. Magnetic resonance imaging (MRI) of the lumbar spine revealed disc desiccation L (Lumbar) 4 - L5 level with diffuse disc bulge and posterior disc herniation causing mild spinal canal stenosis and narrowing of the lateral recesses, pronounced on the right with impingement on the descending L5 nerve roots. There were diffuse bulges at L5 - S1(Sacral) level encroaching on the inferior aspects of the neural foramina bilaterally. Electrodiagnostic studies revealed electrodiagnostic evidence of L5 - S1 radiculopathy bilaterally. 

Under review is the medical necessity of Epidural Steroid Injection. 

The Pain Management Services (Epidural Steroid Injection) is medically necessary for this patient. Per evidence based Official Disability Guidelines (ODG) , epidural steroid injections can be considered when there is evidence of radiculopathy on examination with neurological deficits in a specific dermatomal/myotomal distribution, corroborative findings on imaging studies or electrodiagnostic testing, failure of conservative treatment for at least six weeks to include exercise, physical therapy/chiropractic treatment, and appropriate medications such as nonsteroidal anti-inflammatories, muscle relaxants, and/or adjuvant neuropathic medications such as antidepressants or anticonvulsants. If after the initial block/blocks are given and found to produce pain relief of at least 50-70% pain relief for at least 6-8 weeks, additional blocks may be supported. 

The records indicate the patient has persistent low back pain with radicular symptoms radiating into the lower extremities with numbness, tingling and weakness in the calves and feet. Physical examination reveals diminished motor strength at 4/5 to the bilateral EHL(Extensor hallucis longus) and equivocal straight leg raise bilaterally at 45. The MRI report provided shows clear evidence of disc herniation with impingement on the descending L5 nerve roots with lateral recess narrowing and electrodiagnostic studies revealed evidence of bilateral L5 - S1 radiculopathy. The patient has tried and failed conservative treatment including medications and physical therapy and nothing has helped. There is clear evidence of number radiculopathy eye exam corroborated by MRI and electrodiagnostic studies with failed conservative treatment. The requested lumbar epidural injection is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation.
Treatment inpatient hospital stay.
The insurer denied coverage for inpatient hospital stay.
The denial is upheld.

This is the case of a gentleman that presented to the hospital complaining of palpitations. Upon arrivals the patient was tachycardic with an irregularly irregular heart rhythm. Pulse was 141 beats per minute (bpm) and blood pressure was 122/79. Physical examination revealed no abnormalities. Twelve-lead electrocardiogram revealed atrial fibrillation with rapid ventricular rates. Serum blood testing revealed normal thyroid function studies and no elevation in serum troponin. The patient was treated with atrioventricular (AV) nodal blocking agents and ultimately underwent successful synchronized cardioversion. He was discharged the following day.

This patient presented with symptomatic atrial fibrillation with rapid ventricular rates. Medical therapy was ineffective and direct current (DC) cardioversion restored normal sinus rhythm. The patient was discharged the following day. In a large population study involving individuals presenting with atrial fibrillation, most patients presenting to the emergency department (ED) with atrial fibrillation were treated and discharged within a number of hours. (1) In another large study, patients presenting to the ED with atrial arrhythmia were successfully cardioverted and sent home the same day. (2) Long term follow-up revealed that this strategy was safe and efficacious. The current standard of care is to treat hemodynamically stable patients presenting with atrial fibrillation and atrial flutter with cardioversion without admission to the hospital (or at a lower level of care). In conclusion, inpatient hospital stay was not medically necessary.

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

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical necessity is not substantiated.