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

Diagnosis: Orthopedic/Musculoskeletal- Age-related osteoporosis.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Teriparatide injection (Inj). 
The denial is upheld. 

This is a female diagnosed with age-related osteoporosis without fracture. She has been recommended for teriparatide. As reported; she has tried and failed Ibandronate acid. She tried and failed alendronate due to the onset of bone pain and fatigue. The Fracture Risk Assessment Tool (FRAX) is 7.6 percent (%) and 1.6% respectively. Her Z-score at total left was negative (-)1.6; left forearm was -1.3.
At issue is the medical necessity of Teriparatide injection (Inj).

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

No, the requested health service/treatment of Teriparatide Inj is not medically necessary for this patient.
The use of teriparatide (Forteo) is sanctioned by the American Academy of Clinical Endocrinologists. [1] Forteo is effective for the treatment of osteoporosis and is a first line therapy for women with severe osteoporosis or prior fractures. [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14,[15, 16] Forteo is indicated, and United States Food and Drug Administration (FDA) approved for the treatment of women with osteoporosis who are at high risk of fracture. "These include women with a history of osteoporotic fracture, or who have multiple risk factors for fracture, or who have failed or are intolerant to previous osteoporosis therapy, based upon physician assessment." [17]. A FRAX score of greater than (>) 20% for a major osteoporotic fracture or > 3% for a hip fracture is considered high risk. The patient does not have a high risk of fracture. The patient is not clearly postmenopausal. The patient does not have a history of fracture. The patient's T score and Z score are not in the osteoporosis range. The request is not consistent with generally accepted standards of medical practice.
Therefore, the requested health service/treatment of Teriparatide Inj is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Amyotrophic lateral sclerosis
Treatment: Radicava ORS (oral rehydration solution) Starter Kit, pre-service
The insurer denied the Radicava ORS (oral rehydration solution) Starter Kit, pre-service
The denial is upheld

The member is a male with amyotrophic lateral sclerosis (ALS). The provider has requested Radicava oral suspension. The requested medication was denied coverage as there was no documentation showing he meets the accepted criteria for diagnosis, that he was diagnosed within the last two years, that he has a score of 2 or above on all sub-categories of the amyotrophic lateral sclerosis functional rating scale (ALSFRS) and that he has a forced vital capacity of at least 80%.

No, the proposed treatment is not medically necessary.
The clinical trial leading to the FDA (Food and Drug Administration) approval of Radicava for the treatment of amyotrophic lateral sclerosis only included persons within two years of diagnosis, with an amyotrophic lateral sclerosis functional rating scale score of at least 2 in all sub-categories and at least an 80% forced vital capacity (Yoshino). Studies enrolling persons with more advanced amyotrophic lateral sclerosis failed to demonstrate any benefit. Moreover, subsequent clinical trials have failed to demonstrate any benefit from this medication (Turnbull; Witzel et al.). This member does not have a score of two or more in all subcategories of the amyotrophic lateral sclerosis functional rating scale and therefore no data is available to support that this treatment would be efficacious for him. Therefore use is not appropriate or standard of care and not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is upheld

The patient presented with rectal bleeding. He noticed bright red blood-streaked stool. In the ER (emergency room) he was found to be hemodynamically stable. The abdominal exam was benign. A previous colonoscopy done showed hemorrhoids and diverticulosis. The hemoglobin was 14.9. A colonoscopy was again performed, and hemorrhoids and diverticulosis were found. No active bleeding was seen. 

Clinical indications for admission for Lower Gastrointestinal Bleeding MCG (Milliman Care Guidelines) (M-182) include having ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy, shock index greater than 1, peritoneal signs, and an inability to maintain oral hydration after observation care. 

The patient did not have these conditions. This patient had rectal bleeding and required a colonoscopy. He was not anemic and remained hemodynamically stable. The colonoscopy was negative for active bleeding. The colonoscopy could have been performed on an ambulatory basis and he could have been managed with an observation status. He did not meet MCG criteria for admission for Lower Gastrointestinal Bleeding. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

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

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

Diagnosis: Tooth decay
Treatment: Nerve Treatment on Front Tooth, Tooth 23
The insurer denied the Nerve Treatment on Front Tooth, Tooth 23
The denial is overturned

The patient is a male requesting root canal therapy on tooth #23. Prior denial was for tooth #23 supposedly having less than 50% bone support remaining.

Yes, the requested health service is medically necessary.

The bone levels around all the teeth are seen on the x-rays. Tooth #23 needs a root canal procedure as part of its treatment. The tooth definitely, without question, has more than 50% bone support on both the mesial and distal sides. It has more like 60-70% bone left. This is more than the minimum bone support allowed for authorization for the root canal procedure. The root canal is medically necessary for this tooth and it qualifies for treatment.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal tenderness 
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a male with a medical history of a cholecystectomy 5 years prior. He presented to the emergency department with severe epigastric pain radiating to the left arm. Vital signs were unremarkable. Physical examination was notable for soft, non-distended abdomen with generalized abdominal tenderness worst in the epigastrium. 

The inpatient stay was not medically necessary. The patient presented with choledocholithiasis and concern for cholangitis. However, there was no persistent hemodynamic instability or other complications such as gallstone pancreatitis, hepatic or abdominal abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and choledocholithiasis was addressed (biliary sphincterotomy was appropriately performed); there were no documented complications such as post-ERCP pancreatitis or bleeding. Given lack of complications, and given improvement with therapy, the care provided, including monitoring, labs, imaging, Gastroenterology consultation, and ERCP, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal ulcer disease

Treatment: Upper Gl (gastrointestinal) Endoscopy

The insurer denied coverage for an Upper Gl Endoscopy

The denial is overturned

The patient has a history of gastroesophageal ulcer disease with LA (long acting) Class C (erosion extending over mucosal folds) erosive esophagitis, and it is reported that he had an esophageal ulcer. He was complaining of LUQ (left upper quadrant) abdominal pain. He was treated with PPI (proton pump inhibitor) therapy. An endoscopy was performed, and gastritis was found but the esophagus appeared normal.

MCG (Milliman Care guideline) ACG: A-0203 lists indications for Upper Gl Endoscopy. Severe erosive esophagitis and need for follow up after PPI therapy is listed as an indication for the procedure. Dyspepsia in a patient over 60 years old is also an indication for endoscopy.

This patient had severe esophagitis with an ulcer on a previous endoscopy. He was also having LUQ pain and was over 60 years old. This meets MCG criteria for indications for Upper Gl endoscopy. The health care plan did not act reasonably or with sound medical judgment. The endoscopy was medically necessary.

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

The insurer's denial of coverage for procedure code 43239, diagnostic esophagogastroduodenoscopy (EGD) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis. 
Treatment: Pregabalin (Lyrica). 

The insurer denied coverage for Pregabalin (Lyrica). 

The denial is overturned. 

This case involves a female with request for Pregabalin.  The patient was seen for follow-up visit. It was noted the patient had remained on Lyrica but had been off tramadol with increased back pain. Past medical history was significant for lumbar fusion as well as degenerative disc disease in the lumbar and cervical spine. The patient also had a past medical history significant for diabetes, hypertension, and coronary artery disease as well as psoriatic arthritis. Review of systems was positive for numbness of feet. Treatment plan was for ongoing medication management with Cymbalta, Lyrica, and tramadol. The patient had chronic musculoskeletal pain and was stable on current regimen for over 6 months. It was noted that the patient had tried and failed therapy with gabapentin in the past and was recommended for continuation of pregabalin. The request for pregabalin was denied as there was lack of documentation of failure of first-line medications. The appeal letter reported the patient was experiencing neuropathic pain that was well controlled with Lyrica. It was again reported that the patient tried and failed treatment with gabapentin prior to discontinuation. 

Considering the clinical standards of the plan, the 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 societies, boards and associations, the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. There is documentation that the patient previously tried gabapentin and has been stable on Pregabalin. There is a past history of spinal pathology and fusion with persistent symptoms. Ongoing use would have been and is medically necessary in this case. Denial for step therapy would not be reasonable or with sound medical judgment. 

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 Pregabalin (Lyrica) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Erosive esophagitis. 
Treatment: Esophagogastroduodenoscopy (EGD). 

The insurer denied coverage for Esophagogastroduodenoscopy (EGD). 

The denial is overturned. 

The patient has a history of erosive esophagitis and has been on PPI (proton pump inhibitor) therapy. He was complaining of abdominal pain. Erosive esophagitis was found as well as erosive polypoid inflammation of the duodenum. A repeat endoscopy was performed and gastritis was found. The esophagus showed non-erosive esophagitis. The pathology showed reflux esophagitis but there was no evidence of Barrett's esophagus or dysplasia. The physician has advised that he was doing the procedure to see if the esophageal erosive esophagitis was healing. 

MCG (Milliman Care Guideline) A-0203 lists indications for Upper Gastrointestinal (GI) Endoscopy. Gastroesophageal reflux disease, in a patient who had severe erosive esophagitis and needed a follow up endoscopy after treatment with a PPI, is listed as an indication for the procedure. 

This patient was on chronic PPI therapy for erosive esophagitis. It was appropriate for the physician to determine if the erosive esophagitis was healing as well as the polypoid inflammation of the duodenum. MCG guidelines support the use of endoscopy as a follow up when there is severe erosive esophagitis. The health care plan did not act reasonably or in the best interest of the patient. Doing an Upper Gl endoscopy was medically necessary. 

The denial is overturned. 

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 procedure code 43249, Esophagogastroduodenoscopy (EGD) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain

Treatment: Right lumbar L4-5 medial branch injections

The insurer denied coverage for right lumbar L4-5 medial branch injections

The denial is upheld. 

This patient has chronic low back pain. He takes Baclofen, Buprenorphine and Diclofenac for pain. He is status post left L (lumbar) 3, L4, and L5 RFA (radiofrequency ablation) of the medial branches. He also had decompressive laminectomies at L3, L4 and L5 as well as discectomies at L3-L4 and L4-L5. An EMG (electromyography) shows old bilateral L5 radiculopathy. His physical exam shows normal posture, FULL RANGE OF MOTION WITH FLEXION, EXTENSION AND ROTATION TO THE LEFT AND RIGHT. THERE ARE NO FACET LOADING TESTS DOCUMENTED.

The request is for diagnostic Right MBB (medial branch block) at L4-L5.

Manchikanti (1) published clinical practice guidelines for facet joint interventions which included the need to document clearly the physical exam findings that support facet blocks. The signs and symptoms most frequently found included in a diagnostic scale were 3 symptoms (1- axial or bilateral axial lumbar pain, 2- improvement with rest, and  3- absence of nerve root pattern), 
and may have pseudo radicular pain, however, the pain is greater in lumbar area than pain in the leg. They provided 3 clinical signs: Kemp sign, also referred to as Kemp's test, Quadrant Test: Extension-Rotation test, and Facet Stress Sign. None of these are documented in this patient.

Similarly, Cohen (2) stated the need for a clearly documented physical exam. The absence of clearly documented physical exam supporting the diagnosis of facet disease precludes this intervention. The requested procedure is not medically reasonable or necessary.

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

The insurer's denial of coverage for the outpatient procedure (64493) x 2 right lumbar L4-5 medial branch injections for pain management is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented with chest pain of four hours. Aspirin (ASA) and nitroglycerin (NTG) were given in the ambulance. The patient was on Plavix and had a history of clots in the brain. The patient's electrocardiogram (EKG) showed T wave inversion in V2 (ventricle) . Cardiac enzymes were negative. A computed tomography angiogram (CTA) was performed. The nuclear scan was "abnormal". Her calcium score was zero.

The patient was admitted to telemetry for observation, monitoring and pain control.  She was discharged with a diagnosis of chest pain.

No, the proposed inpatient hospital admission was not medically necessary.  Inpatient level of care was neither necessary nor provided.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were unlikely to be representative of acute coronary syndrome.  The patient's calcium score of zero is indicative of minimal probability of significant coronary artery disease (CAD).  The patient's exam and cardiac findings were equivocal. Biomarkers and electrocardiogram showed no evidence of acute ischemia. Her chest x-ray was normal.  The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous nitroglycerin.  

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.  The statement that this patient could not be "managed" in an outpatient setting is not consistent with guidelines or usual community practice. While there is always a potential for an adverse event (and in this case a low probability), one did not happen and no actual treatment was added. There are no examples of care requiring inpatient level of care.  It is not the risk that something might occur, but the actual treatment and care provided.

Milliman criteria requirements for admission for unstable angina were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present. Since all testing and therapy would be appropriate, safe and guidelines consistent in a lower level of care, inpatient level of care was not medically necessary.

This denial explanation was consistent with guidelines and usual community care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld. 

This is a case of a male with a history of hypertension, diabetes mellitus and coronary artery disease who presented to the hospital complaining of poorly controlled blood pressure (BP) and shortness of breath following transition from carvedilol 25 mg (milligrams) BID (twice daily) to Norvasc 5 mg daily. Upon arrival to the hospital, vital signs were stable: BP 145/75 mmHg (millimeters of mercury), Pulse 81 bpm (beats per minute). Physical exam was significant for pitting edema in both lower extremities. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm without ST (interval on ECG) or T (interval on ECG) wave abnormalities. Serum blood testing revealed high sensitivity troponin of 66 ng/L (nanograms per liter) (normal < [less than] 50 ng/L). Serum creatinine was elevated (2.8 mg/dl [milligrams per deciliter]). Serum pro-BNP (brain natriuretic peptide) was not elevated (252 pg/ml [picograms per milliliter]). The patient was admitted to the hospital and treated for hyperglycemia. No therapy for congestive heart failure was administered and the patient was discharged on the same day with outpatient follow up.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. This patient presented with dyspnea pedal edema and no elevation of pro-BNP level. He noted that his dyspnea was related to a change in BP medications and noncompliance with furosemide therapy. He had taken furosemide just prior to presentation and was appropriately treated with guideline directed medical therapies (Reference 1). Masri, et al compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated no difference in mortality between the two groups (Reference 2). In conclusion, this patient could have been treated at a lower level of care and did not require inpatient hospital admission.

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

Diagnosis: Asthma Exacerbation.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) an asthma exacerbation. Vital signs were notable for tachycardia, tachypnea, and bilateral expiratory wheezing. The physical exam was notable for unable to speak full sentences, benign abdominal examination. Lab work was remarkable for thyroid stimulating hormone (TSH) 0.01 and thyroxine (T4) greater than (>) 7.8. A chest x-ray (CXR) showed no acute abnormality. An electrocardiogram (EKG) showed tachycardia. The patient was diagnosed with an asthma exacerbation and thyroid storm and treated with a nebulizer, bi-level positive airway pressure (BiPAP), steroids, magnesium, methimazole, diltiazem, and Versed. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was medically necessary at an acute inpatient level of care. 

This patient presented to the ED with acute respiratory distress requiring aggressive treatment with nebulizers, steroids, and non-invasive ventilation. The patient's clinical status was further complicated by the high clinical suspicion and concern for a thyroid storm, given the laboratory, cardiac, and gastrointestinal (GI) manifestations. Thyroid storm is a potentially life-threatening complication of hyperthyroidism and the patient needed close clinical monitoring to evaluate for cardiac arrhythmias, high output cardiac failure, seizures, delirium, coma, and thromboembolism, while being treated with the appropriate medications and monitoring for clinical response. Overall, this patient presented with a serious and complex clinical picture requiring treatment and clinical monitoring that could not have been safely provided at a lower level of care.