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

Diagnosis: Abscess
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is an adult patient with a past medical history significant for syphilis and asthma who presented to the emergency department with complaints of perianal pain. Vitals on presentation included: Temperature 37.8 degrees Celsius, Blood Pressure 162/90, Pulse 98, Respiratory Rate 16, Oxygen Saturation 100%(percent) on Room Air. Laboratory results included the following: White Blood Cell (WBC) count 14.3, Hemoglobin 16.0, Hematocrit 47.6, creatinine 1.00, and glucose 106. The patient was admitted for a perianal abscess. The patient was treated with intravenous fluids and intravenous (IV) antibiotics (ampicillin). A Computed Tomography (CT) scan revealed a perianal collection on the left side of perineum. Surgery evaluated the patient and performed an incision and drainage with drain placement. The patient tolerated the procedure, remained afebrile, hemodynamically stable, and was discharged on oral antibiotics (Augmentin) to continue and follow-up as an outpatient.

According to documentation, the patient presented with a perirectal abscess. The patient had a low-grade fever (100.0 degrees Fahrenheit), and was hypertensive. Laboratory results showed an elevated WBC of (14.3). Based on above findings, the hospital admission was medically necessary for intravenous antibiotics and surgical intervention (incision and drainage in the operating room). Prior determination of denial of inpatient stay is overturned.

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

Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient is a toddler with history of 3 days of fever and 2 days of coughing. On the day prior to the admission the child was having difficulty breathing and was taken to the Emergency Room (ER). In the ER the child was treated with Combivent inhalation therapy and prednisone. The child tested positive for the respiratory syncytial virus (RSV) and was discharged home from the ER to continue taking albuterol every 4 hours. Despite this treatment the child continued to have difficulty breathing and coughing so the mother decided to return with the child to the ER for additional treatment.

There is a past medical history significant for a Coronavirus (COVID-19) infection in and a previous respiratory illness which required treatment with oxygen with a High Flow Nasal Cannula (HFNC). Following this illness, the pediatrician had prescribed daily inhalation treatment with budesonide, but the mother stopped administering this treatment 2 weeks prior to this illness.

In the ER, the patient was noted to be in respiratory distress with subcostal and intercostal retractions. On physical examination there were coarse breath sounds heard bilaterally. The child was treated with an intravenous (IV) bolus of normal saline because there had been a decrease in oral intake and urine output. The child was again treated with methylprednisone and albuterol in the ER. A chest X-ray demonstrated increased peribronchial lung markings. Since the child had been treated in the ER the day prior to returning to the ER and failed outpatient management with bronchodilator and steroid therapy the decision was made to admit to the hospital for continued treatment with albuterol every 2 hours and continue IV fluids with a diagnosis of bronchiolitis.

The patient was treated appropriately in the ER for a respiratory illness with fever, coughing, and persistent respiratory distress with decreased oral intake and urine output. The patient had been seen in the ER the day prior to the admission and was diagnosed with RSV viral illness. When the child failed outpatient treatment with prednisone and albuterol every 4 hours the mother returned to the ER. Since the child had respiratory distress with subcostal and intercostal retractions the decision to admit for continued albuterol every 2 hours was consistent with the standard of care for a toddler with bronchiolitis. The child could not have been discharged safely since the symptoms had failed to improve with outpatient therapy. 

Based on the above, the insurer's denial must be overturned. The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, obesity, hypertension, osteoarthritis

Treatment: Personal care worker (PCW) services 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week

The insurer denied coverage for personal care worker (PCW) services 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week

The denial is overturned

This is a morbidly obese elderly patient with diabetes, hypertension, and osteoarthritis. The patient lives alone in a 1-bedroom apartment. The insurer reduced the patient's previously approved split-shift hours to 7 days per week, 24 hours per day, live in; 91 hours per week. The patient is requesting reinstatement of Personal Care Worker (PCW) services 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's Cognitive skills are described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient requires maximal assistance for bathing, dressing and bed mobility. Extensive assistance is needed for personal hygiene and eating. The patient is totally dependent for locomotion and is non-ambulatory. The patient is also completely incontinent of bowel and bladder. The patient is cognitively impaired, essentially maximal assistance for Activities of Daily Living (ADL), fully incontinent and bedbound. Based on the records reviewed, the currently approved live-in PCW is unlikely capable of providing for the patient's functional needs while having the ability to consistently obtain an uninterrupted 5 hours of sleep. The patient is at particularly high risk for additional falls, pressure ulcers and recurrent respiratory infections. Bed repositioning approximately every 2 hours is necessary to prevent decubitus ulcers. The patient's health and safety are more appropriately provided and maintained at home with the reinstatement of PCW services 24 hours/day, 7 days/week split shift.

From a physical medicine and rehabilitation perspective, PCW services 7 days/week, 24 hours/day, continuous care by more than 1 person; 168 hours/week is medically necessary.

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 personal care worker (PCW) services 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Fevers and Vomiting.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is a young adult female, who was admitted for fever and abdominal pain. She was diagnosed with urinary tract infection and started on intravenous antibiotics and fluids. The patient's condition responded appropriately, and she was discharged in stable condition on the third day.

The proposed treatment was not medically necessary.

The patient was admitted for urinary tract infection. During this hospital stay, the patient remained hemodynamically stable and responded appropriately to antibiotics therapy. Patients with uncomplicated urinary tract infection (e.g., no persistent fever, no flank pain) are treated as outpatients (if no other indication for admission is present). [1,2] Some patients with uncomplicated upper urinary tract infection (e.g., hemodynamically stable, able to maintain hydration orally) do not require inpatient admission. [3] Database analysis including 572,479 adult visits to an emergency department for urinary tract infection found an inpatient admission rate of 17%. [4] Another analysis of a national database found that out of more than 1.5 million 
visits to the emergency department for pyelonephritis, 27% were admitted to inpatient care. [5]

This patient was hemodynamically stable, did not have persistent fevers, and did not have complicated urinary tract infection. Therefore, per standard of care and evidence-based literature, inpatient admission was not medically necessary, and lower level of care was more appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3

Diagnosis: Low back pain

Treatment: Lower back spinal nerve thermal (heat) destruction, code 64628

The insurer denied coverage for lower back spinal nerve thermal (heat) destruction, code 64628

The denial is upheld

This patient has chronic low back pain. He takes non-steroidal anti-inflammatory drugs (NSAIDs) and Tylenol for pain. He has had epidural steroid injections (ESI), medial branch blocks and radiofrequency ablation (RFA), sacroiliac (SI) joint injections as well as dorsal root ganglion (DRG) stimulation. His magnetic resonance imaging (MRI) shows Modic changes at lumbar (L) 1, L4 and L5. It also shows multi-level disc bulges and facet arthropathy. The request is for RFA of the basivertebral nerve (BVN) at L4 and L5.

The publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates. There are other evidence based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:
Industry funding is a potential source of study bias for the available data reviewed.
Limited number of studies.
Short-term follow up for the majority of studied patients.
Unknown effect on the primary degenerative process

Urits et al (5)) also commented on the need for more research on this promising technique: "reproducible large randomized controlled trials (RCTs) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RFA in the management of chronic lower back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

In sum, this procedure is NOT likely to be more beneficial than the standard of care.

The denial of lower back spinal nerve thermal (heat) destruction, code 64628 and coverage for the requested treatment should be upheld. 

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 

This is an adult that presented to the hospital for elective cardiac catheterization following a positive stress test.  Prior to stress testing, the patient reported symptoms of chest pain and dyspnea after meals. Past medical history was relevant for coronary artery disease, hypertension and apical variant hypertrophic cardiomyopathy. Cardiac catheterization revealed 90%(percent) lesions in the mid left anterior descending (LAD) artery and proximal ramus intermedius artery. Left ventricular (LV) ejection fraction was 55%. Drug eluting stents were placed in both vessels. No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization. Findings demonstrated a 90% lesion in the proximal left anterior descending artery and an 80% lesion in the proximal left circumflex artery. Stents were placed in both arteries. His perioperative course was uncomplicated, and he was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care. The patient could have been managed at a lower level of care.

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 admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Obesity.
Treatment:  Saxenda (Iiraglutide).

The insurer denied coverage for Saxenda (Iiraglutide).  The denial is upheld .
 
This patient is an adult who has obesity. She was started on Saxenda. The pre-Saxenda body mass index (BMI) was 36 kilograms per meters squared (kg/m2), and her body weight was 230 pounds (lbs). The notes indicate that the patient had not lost any weight on the 1.8 milligram (mg) dose of Saxenda and was advised to increase the dose to 2.4 mg.
        
This patient is taking Saxenda and has baseline body weight of 230 lbs. A note indicated that patient had not lost any weight on the 1.8 mg dose. However, it is not known if the patient has lost any body weight using Saxenda, as there are no weight records. Continuation of Saxenda without demonstrating 4 percent (%) of baseline body weight loss is not recommended by the manufacturer or medical guidelines.      

Saxenda (Iiraglutide) is not considered medically necessary for this patient.

Per the manufacturer and Food and Drug Administration (FDA) (2020), "Evaluate the change in body weight 16 weeks after initiating SAXENDA and discontinue SAXENDA if the patient has not lost at least 4% of baseline body weight, since it is unlikely that the patient will achieve and sustain clinically meaningful weight loss with continued treatment." 

"The effect and safety of Semaglutide and Liraglutide on weight loss in people with obesity or overweight were evaluated by a Network Meta-Analysis system to provide an evidence-based reference for clinical treatment. Methods: Computer searched PubMed, Embase, and Cochrane Library databases to collect Liraglutide and Semaglutide injection monotherapy randomized controlled trials (RCTs) until April 2022, using Stata 16 software for Network Meta-Analysis. Results: Twenty-three RCTs study with 11,545 patients and 4 interventions (semaglutide 2.4mg, semaglutide 1.0mg, liraglutide 3.0mg and liraglutide 1.8 mg) were finally included. In terms of efficacy, semaglutide 2.4mg (-12.47 kg (kilograms)) had the best weight loss, followed by liraglutide 3.0mg (-5.24 kg), semaglutide 1.0mg (-3.74 kg) and liraglutide 1.8mg (-3.29 kg). Conclusion: This meta-analysis indicates that all GLP-1RAs (Glucagon like peptide-1 receptor agonists) were more efficacious than placebos in people with obesity or overweight on efficacy. Semaglutide 2.4mg has an absolute advantage in weight loss and decreased HbA1c (glycated hemoglobin), but the incidence of total adverse events is also the highest and can cause hypoglycemia. In addition, although liraglutide 3.0 mg was less effective than semaglutide 2.4 mg, serious adverse events were still the most elevated." (Xie, Z., Yang, S., Deng, W., Li, J., Chen, J. 2022).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Saxenda (Iiraglutide) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right tibia stress fracture. 
Treatment: Skilled Nursing Facility. 

The insurer denied coverage for Skilled Nursing Facility. 

The denial is upheld. 

This is an adult patient with medical problems including post-traumatic stress disorder (PTSD), hypothyroid and anemia. The patient fell and sustained a right tibia stress fracture. The patient was transferred from the hospital to a Skilled Nursing Facility (SNF) with right lower extremity non-weight bearing restriction. The patient was eventually advanced to partial weight bearing and was discharged home. Under review is the medical necessity for a continued inpatient stay in a Skilled Nursing Facility. 

The patient was initially an appropriate candidate for the SNF subacute rehabilitation care for the time period under review. (1, 2, 3) The patient had physical impairments that were amenable to subacute rehabilitation services. An additional week of skilled therapy services was reasonable to improve the patient's functional mobility after advancing the right lower extremity weight bearing status to partial. According to the physical therapy note, "resident is now independent with bed mobility, transfers and ambulation in room and on unit with bilateral crutches while partial weight bearing on the right lower extremity." The patient could have been safely discharged to a lower level of care (home with outpatient physical therapy services). The patient also complained of right lower extremity swelling and a Doppler study performed on which was negative for deep venous thrombosis. There were no additional acute medical or complicated nursing issues to support continued stay. 

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. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for continued stay in a Skilled Nursing Facility is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

Patient is an adult who was seen in the emergency department (ED) with complaints of chest pain and shortness of breath (SOB). Patient had a significant history of pulmonary embolism (PE) for which she was on Eliquis, Sickle Cell Anemia, and Lung Cancer status post Lobectomy. 

At presentation her vital signs were normal and her oxygen saturation on room air was 99%.

The patient was diaphoretic and tachypneic and was noted to be speaking full sentences. Lungs were clear. White blood cell count was 7.5 and Hemoglobin was 9.5. Mild hyperkalemia to 5.1 noted. Venous blood gas revealed pH (acidity) 7.37/ carbon dioxide (CO2) 46/ oxygen (O2) 29.  There was concern for PE so a computed tomography (CT) Angiogram was done - no PE noted.  The patient had some small effusion, bronchiectasis and atelectasis and post operative changes.

Patient was treated with intravenous (IV) steroids, bronchodilators and IV fluids. The patient developed increased work of breathing (WOB) and required to be placed on bilateral positive airway pressure (BIPAP) for hypercapnic respiratory failure. Patient slowly improved with current treatment and was taken off BIPAP and discharged home on oral steroids and bronchodilators.

Given COPD exacerbation and hypercapnic respiratory failure requiring noninvasive ventilation with BIPAP, admission was appropriate. This patient was not safe to be managed in a lesser setting.

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: systemic lupus erythematosus (SLE).
Treatment: Anifrolumab-fnia Injection.
The insurer denied Anifrolumab-fnia Injection. 
The health plan's determination is overturned.

The patient is a female with a history of severe systemic lupus erythematosus (SLE) with manifestations that include significant cutaneous disease (cutaneous vasculitis of the palms/soles, discoid lesions, oral ulcers, alopecia), systemic symptoms such as non-infectious fevers, lupus hepatitis, and class III lupus nephritis. 

Anifrolumab-fnia is medically necessary to control refractory SLE with significant cutaneous and systemic features and uncontrolled disease despite the current and past use of multiple medications including current use of high doses of steroids, Plaquenil, full dose CellCept, and history of recent Rituximab/IVIG(intravenous immunoglobulin)/Cytoxan/azathioprine use.
It is well known that SLE can be a severe and life-threatening disease, especially among the pediatric population. Almost universally, medications that are not Food and Drug Administration (FDA) approved for pediatric SLE have to be used to control the disease. Furthermore, this patient has been on several medications with ongoing disease activity and ongoing morbidity related both the SLE and to her current use of high doses of steroids. Steroids have significant side effects and it is in the patient's best interest to trial a medication such as anifrolumab which may provide benefit and have steroid-sparing effects. Anifrolumab may be particularly useful given her history of significant cutaneous involvement and the known benefit of anifrolumab among patients with severe cutaneous disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite, crowding
Treatment: Braces
The insurer denied braces.
The determination is overturned.

The patient has an anterior crossbite on teeth 7 and 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite. At issue is the medical necessity of braces.

This patient presented with an anterior crossbite on teeth 7 and 10, as well as significant 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. (1,2,3) 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. For this reason, the requested treatment is medically necessary.