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

Diagnosis: Myocardial Infarction
Treatment: External defibrillator
The insurer denied an external defibrillator. The health plan's determination is upheld. 

The patient is a man with hypertension who suffered a non-ST elevation myocardial infarction. Cardiac catheterization showed a 95% ulcerated lesion of the left anterior descending and diagonal branch. There was a 90% proximal left circumflex stenosis and a 20-30% right coronary plaque. Ejection fraction (EF) was 30% by left ventriculography. An External Defibrillator (LifeVest) was prescribed. He used the LifeVest.

The External Defibrillator, or LifeVest, is not likely to be more beneficial than any other standard treatment for this patient. He has coronary disease, had an acute myocardial infarction and underwent percutaneous coronary revascularization. A wearable defibrillator is considered appropriate for patients who require explant of an implantable cardioverter defibrillator (ICD), have contraindications which delay ICD implant (such as infection) or are on the waiting list for cardiac transplant. The American Heart Association (AHA) Science Advisory considers use of wearable defibrillators for patients in ischemic heart disease with recent revascularization (the clinical situation for this patient) a class IIB indication, meaning that there is some divergence of opinion, but the weight of evidence is not in favor of the therapy.
The LifeVest is not medically necessary for this patient post-myocardial infarction, post-revascularization, with decreased left ventricular function.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Epigastric pain, change in mental status
Treatment: Continued Inpatient Hospital Admission
The insurer denied the Continued Inpatient Hospital Admission
The denial is overturned, in part.

The patient is a male who has a history of scleroderma. The patient was followed by a rheumatologist. The patient presented with epigastric pain. The patient also evidenced a change in mental status and was intubated and maintained on a ventilator. There was a concern for aspiration pneumonia. 

The patient's medical history was significant for systemic scleroderma, lupus complicated by end-stage renal disease on dialysis via left upper extremity arteriovenous (AV) fistula, personality disorder with previous psychiatric hospitalizations, and opioid abuse disorder.  He was initially admitted for abdominal pain and missed hemodialysis sessions. The hospital course was complicated by computed tomography (CT) imaging showing intra-abdominal fluid collection with concern for possible abscess, and left renal hematoma. Surgery and interventional radiology (IR) were consulted but there was no indication for drainage. The patient had not received antibiotics. A rapid response was called for altered mental status and concern for seizure activity in the setting of hypoglycemia.  The patient was transferred to the medical intensive care unit (ICU) for video electroencephalography (EEG) monitoring and was started on Depakote.  The patient was also noted to have a presenting hemoglobin of 6.6.

Yes, in part; the inpatient admission was medically necessary for the last 27 days of the admission; however, inpatient admission was not medically necessary for the first 21 days of admission. 
The initial admission was due to the profound anemia and electrolyte disturbances. The patient was focused on his pain. Non-compliance was a hallmark of this period of care.  The patient was stabilized.  The first 21 days of the admission did not require acute inpatient admission and was not medically necessary as the patient was stable.

However, the patient evidenced seizure activity in the setting of hypoglycemia. He was intubated and transferred to an intensive care unit setting. The patient had further altered mental status (AMS) (requiring intubation, self extubation), sepsis, methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, aspiration pneumonia (PNA), anemia (requiring multiple transfusions likely due to chronic kidney disease [CKD]), candidemia (blood culture [BCx] likely intraabdominal source) and imaging with interval development of two new abscesses in mid lower abdomen (not amendable to drainage) and possible proctocolitis.  The patient was on 10% dextrose (D10) for refractory hypoglycemia.  

The patient was then transferred out of intensive care unit (ICU); however, around nine minutes into hemodialysis (HD), he had a change in mental status and seizure like activity. He was rescreened into the medical intensive care unit (MICU), placed on bi-level positive airway pressure (BIPAP) and weaned to nasal canula (NC).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Trigeminal neuralgia
Treatment: Trigeminal Nerve Block
The insurer denied the Treatment: Trigeminal Nerve Block.
The denial is upheld.

The patient is a female. He has history of left >right Trigeminal neuralgia in the distribution of V2 (maxillary nerve), V3 (mandibular nerve). She has tried multiple pain medications.

Per a note, the patient has tried gabapentin, Lyrica, fentanyl, valium, phenytoin, and carbamazepine. 

Per a note, the patient is s/p (status post) CPA (cerebellopontine angle) tumor resection and VP (Ventriculo-Peritoneal) shunt, history of trigeminal neuralgia in the V2 (maxillary nerve), V3 (mandibular nerve) distribution. She tried oxcarbazepine, baclofen, and Cymbalta.

Per a note, the patient had follow up for medications, controlled with carbamazepine.

Per a note, the patient was transitioned to lamotrigine and weaned off carbamazepine.

Per a note, the patient weaned lamotrigine, on carbamazepine and gabapentin.

Per a note, the patient had right trigeminal nerve block with steroids under ultrasound guidance. 

Per a note, the patient was status post trigeminal nerve block with 80-95% relief, repeat every 10-12 weeks.

Per a note, the patient had right trigeminal nerve block with steroids under ultrasound guidance.

Per a note, the patient had 100% relief, repeat block.

Per a note, the patient had right trigeminal nerve block with steroids under ultrasound guidance.

Per a note, the block did not work well as before, repeat block.

Per a note, the patient had right trigeminal nerve block with steroids under ultrasound guidance.

Per a note, the patient had 100% relief of pain. The plan was for stim wave neuromodulation, increase lacosamide.

The request is for authorization for repeat trigeminal nerve block.
 
No, the health plan should not cover the Trigeminal nerve block (64400x1).

No, the Trigeminal nerve block (64400x1) is not likely to be more beneficial.

The patient has history of bilateral Trigeminal neuralgia in the distribution of V2 (maxillary nerve), V3 (mandibular nerve). The patient has tried multiple pain medications. The patient receives right trigeminal nerve block every month since earlier in the year, which helps temporarily.

However, there is not enough scientific peer-reviewed literature that supports the routine use of trigeminal nerve block as well as repeat trigeminal nerve blocks for trigeminal neuralgia. Therefore, the health plan should not cover the Trigeminal nerve block (64400x1).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Trigeminal neuralgia
Treatment: Trigeminal Nerve Block
The insurer denied the Treatment: Trigeminal Nerve Block.
The denial is overturned. 

The patient female. She has trigeminal neuralgia and has been treated with trigeminal nerve blocks.  

Yes, the health plan should cover the Trigeminal nerve block (64400 x 1).

Yes, the Trigeminal nerve block (64400 x 1) is likely to be more beneficial.

The patient is a female with trigeminal neuralgia who has a complicated history of brain tumor that was resected, and resultant facial pain. She has had trigeminal nerve blocks in the past with near 100% relief.  Often these nerve blocks gave greater than two months of relief.  
The patient has previously tried and failed multiple medications indicated for trigeminal neuralgia (TN) and has had side effects that include hyponatremia, which can be life threatening. Other options are more invasive and often carry greater morbidity and mortality associated with the procedure. RF (radiofrequency) of the gasserian ganglion is a possibility but is considerably more complicated and the risks are greater. Other surgical options are more invasive and carry significant risks that often outweigh the benefits.  In addition, surgical decompression of the trigeminal nerve often yields poor results.  Peripheral nerve stimulation is an emerging treatment option but has not been shown to be effective in RCT (randomized controlled trials).  

The patient has tolerated the nerve blocks in the past with great success and has been shown to be effective in the management of TN (trigeminal neuralgia).  Given her failure to conservative treatment, and the lack of viable alternatives, the requested nerve block is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical radiculopathy
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld. 

The patient is an adult female with history of cervical radiculopathy.  She was scheduled for surgery and instructed to come to emergency room.  She presented to the emergency department with posterior neck pain and decreased sensation in the left arm and right leg.  She had presented to the emergency room earlier that month and was started on prednisone.  The patient's physical examination revealed global decreased sensation in the left upper and right lower extremities and brisk reflexes with positive Hoffman's, and left biceps and wrist extension weakness.  Magnetic resonance image (MRI) revealed a C (cervical) 5-6 disc herniation and she was subsequently taken to surgery for anterior cervical discectomy and fusion.  A drain was placed in surgery and removed the following day.  The patient was transitioned to oral pain medications and discharged home.

No, the inpatient hospital admission was not medically necessary.

Single level anterior cervical discectomy and fusion is typically an outpatient procedure. This patient's surgery was performed without complication.  The surgical drain could have been removed as an outpatient the day following surgery.  The patient could have been discharged the same day as the procedure, as such the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-ST elevation myocardial infarction (NSTEMI). 
 Treatment: Full hospital admission. 

The insurer is denied coverage for full hospital admission. 

The denial is overturned. 

This male patient has a history of heart failure, cerebrovascular accident (CVA), iron deficiency anemia, tubulovillous adenoma, epistaxis, and hyperlipidemia (HLD). 

The patient met inpatient criteria. He presented with epistaxis, severely low blood counts, acute kidney injury, along with chest pain and cardiac biomarker positivity. Despite having no acute ischemic electrocardiogram (EKG) changes, his clinical presentation was high-risk. While there was no hemodynamic instability, inpatient level of care was appropriate and indicated. He had critically low anemia with evidence of end-organ dysfunction, namely myocardial damage, and acute renal insufficiency with a 25% rise in serum creatinine from baseline. The patient required acute intervention with blood transfusion. Care provided at a lesser level of service than inpatient would be clinically out of the standard of practice and does not represent the standard of care, as it would have put the patient at increased risk for major adverse outcomes. 

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 full hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: periodontal disease

Treatment: D4341 deep gum and root cleaning of the upper right quadrant, upper left quadrant, lower left quadrant, and lower right quadrant

The insurer is denied coverage for D4341 deep gum and root cleaning of the upper right quadrant, upper left quadrant, lower left quadrant, and lower right quadrant.

The denial is overturned. 

This is a male with no documented history.

In this case, as regards documentation of the periodontal status, in particular the periodontal charting and radiographs, it is evident that there is a level of periodontal disease where there is root surface exposure and alveolar bone loss. All four quadrants exhibit multiple areas of 7 mm pocket depths and radiographic calculus is noted particularly in the molar areas. Appropriate treatment would be the recommended scaling and root planing to address any ongoing periodontal issues. This would be the standard of care treatment given the alveolar bone loss and level of periodontal disease documented on the clinical and radiographic findings. As such these services are considered dentally necessary.

Dental deep gum and root cleaning of the upper right quadrant, upper left quadrant, lower left quadrant, and lower right quadrant is medically necessary as the clinical and radiographic documentation support and substantiate this recommended treatment.

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 D4341 deep gum and root cleaning of the upper right quadrant, upper left quadrant, lower left quadrant, and lower right quadrant is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: varicose veins

Treatment: code(s) 37799-RT - Other Artery and Vein Procedures

The insurer is denied coverage for code(s) 37799-RT - Other Artery and Vein Procedures

The denial is upheld. 

This female patient has a history of large, painful varicose veins of the left calf posterior calf.

The procedure performed, a microphlebectomy of varicose veins, is appropriate in the context of veins which are well-documented in the record to be associated with typical symptoms of venous insufficiency. In order to qualify as medically necessary, the symptoms must not only be typical of venous insufficiency but need to be documented to interfere with activities of daily basis. Such information as this would likely be included in medical records preceding the date of the procedure, such as a history and physical, a consult note, or other similar records.

In addition, in order for this procedure to qualify as medically necessary there needs to be a detailed ultrasound report including superficial and deep reflux studies. A phlebectomy procedure such as this might be appropriate when the patient has legitimate bona fide significant symptoms that interfere with daily activity in the absence of axial reflux on the great saphenous or short saphenous veins. In this case, there is no ultrasound data provided.

As the basic criteria for medical necessity of venous procedures for treatment of superficial venous insufficiency (documentation of bona fide legitimate significant symptoms interfere with daily activity, as well as the absence of axial reflux prior to performing a local phlebectomy such as this) are not satisfied, the procedure does not qualify as medically necessary.


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

The carrier's denial of coverage for the code(s) 37799-RT - Other Artery and Vein Procedures is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: coronary artery disease, hypertension, hypothyroidism

Treatment: personal care assistant (PCA) services of 24 hours per day, 7 days per week (split shifts) for a total of 168 hours per week

The insurer denied coverage for personal care assistant (PCA) services of 24 hours per day, 7 days per week (split shifts) for a total of 168 hours per week

The denial is upheld.

According to the medical records, the patient is a female who lives alone in a senior housing apartment complex. She had a recent fall that led her to an inpatient stay in a rehabilitation and nursing care facility. After that stay, she was reevaluated for an increase in her personal assistant hours. She was granted 84 hours per week. The patient appealed this decision and is requesting 168 hours per week which is around the clock care, seven days per week.

The health care plan acted reasonably and with sound medical judgment and is in the best interest of the patient. The health care plan rightfully denied 168 hours of personal assistance, which is equivalent to around the clock care seven days a week.      

The assessment indicates that the patient requires extensive to maximal assistance with activities of daily living (ADLs). She requires meal prep but can eat independently. She has mixed incontinence with some control present and does require the use of adult incontinence products. The patient does not require care while sleeping such as turning and repositioning/bed mobility. The 84 hours a week/12 hours a day previously approved can be split so that her caregiver is there when needed the most. The patient also has a PERS (personal emergency response system) device and is able to activate if urgent care is needed as her memory is in tact and she is able to make her needs known.

Therefore, 168 hours per week is not necessary in this case and the patient's needs can be met with 84 PCA hours per week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis And Psoriatic Arthritis
Treatment: Taltz
The insurer denied the request for Taltz
The denial is overturned.

The patient is an adult male with severe psoriasis affecting the trunk and extremities, as well as psoriatic arthritis. He has tried and failed Otezla, Stelara, and triamcinolone. He has a strong family history of cancer, and his dermatologist does not think TNF (tumor necrosis factor) alpha inhibitors are an appropriate choice for him.

Yes, the treatment with Taltz is medically necessary.

Based on the available information, results of head-to-head clinical trials, and black box warnings associated with Tremphya, Cimzia, and Cosentyx, Taltz is the most appropriate treatment choice for this patient. 

The patient has severe psoriasis and psoriatic arthritis.  Taltz is indicated for adults with active psoriatic arthritis (PsA), for adults with active ankylosing spondylitis (AS), and for adults with active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation.  Taltz is also indicated for patients aged six years or older with moderate-to-severe plaque psoriasis (PsO) who are candidates for systemic therapy or phototherapy.

In clinical trials, Taltz established superiority to Tremfya across all efficacy endpoints through week 12. Cosentyx has a greater number of possible adverse events.  Side effects of Cosentyx that are different from Taltz include diarrhea, oral herpes, hives, tonsillitis, oral thrush, impetigo, inflammatory bowel disease, ear infection, eye infection or inflammation (conjunctivitis), increased liver transaminases, and low white blood cell count (neutropenia).  These drugs have not been directly compared in clinical studies.  However, one review of studies of plaque psoriasis found that Taltz was more effective than Cosentyx at reducing symptoms of psoriasis.  In the meta-analysis of studies with active comparators, PASI (Psoriasis Area and Severity Index) 90 response rates were 127% [95% confidence interval [CI] 55198, P = 00005], 100% (95% CI [confidence interval] 21180, P = 001) and 112% (95% CI [confidence interval] 32191, P = 0006) higher and PASI (Psoriasis Area and Severity Index) 100 response rates were 117% (95% CI [confidence interval] 59175, P < 0001), 127% (95% CI [confidence interval] 60194, P < 0001) and 131% (95% CI [confidence interval] 63199, P < 0001) higher for ixekizumab compared with secukinumab.  Ixekizumab had higher PASI 90 (Psoriasis Area and Severity Index) and PASI (Psoriasis Area and Severity Index) 100 responses at week 12 compared with secukinumab using adjusted indirect comparisons.  Cimzia, like other TNF (tumor necrosis factor) alpha inhibitors, has a black box warning for lymphoma and other malignancies, some fatal, reported in patients treated with TNF (tumor necrosis factor) blockers.

Therefore, based on the above, and based on the patient's medical and family history, Taltz is the most appropriate choice of biologic therapies and is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriatic arthritis.

Treatment: Gammaked.

The insurer is denied coverage for Gammaked.

The denial is upheld. 

This female patient has a history of psoriatic arthritis (PsA), Lyme's disease, obesity, gastroesophageal reflux disease, partial hysterectomy, liver resection, depression, and anxiety.

The patient has had only one IgG(immunoglobulin G) determination that was modestly low, in the setting of a chronic inflammatory disease (PsA) and steroid therapy. Other than past Lyme Disease there is no history of recurrent infections. She has persistent hot/cold flashes. There is no documented fever. Review of the UpToDate articles "Overview of intravenous immune globulin (IVIG) therapy" and "Clinical manifestations, epidemiology, and diagnosis of common variable immunodeficiency in adults" does not lend support for treatment other than for infections. That assumes that other etiologies of low IgG are excluded and there are clinical endpoints to follow. 

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

The carrier's denial of coverage for the Gammaked is upheld.  The medical necessity is not substantiated.