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

Diagnosis: left lower extremity venous disease
Treatment: outpatient procedure (37785 x1, 37765 x1, 37766 x1, 37799 x1)
The insurer denied coverage for outpatient procedure (37785 x1, 37765 x1, 37766 x1, 37799 x1).
The denial is upheld. 

This is an adult who is being evaluated for treatment of left lower extremity venous disease. Her diagnoses are left leg varicosities, anxiety, back pain, and obesity. 

The insurer has denied coverage for outpatient procedure (37785 x1, 37765 x1, 37766 x1, 37799 x1). In their Final Adverse Determination letter, they write that the criteria for this procedure are not met because this type of procedure is covered when it is being done with or after another type of procedure called saphenous vein stripping or ablation. The records do not show that either of those are being done." 

The history and physical described varicosities are on the front of the leg.

The Venous Duplex found no saphenous reflux. The majority of documented veins are under three (3) millimeters (mm) and no venous reflux is documented.

Milliman Care Guidelines: Stab Phlebectomies can be approved when associated with saphenous truncal ablation/stripping. In accordance treatment of any venous disease including as requested for this patient stab phlebectomy to the left leg requires not only significant documented venous reflux disease but also, veins larger than 3 mm, both of which are not documented.

The veins to be treated with this proposed stab phlebectomy (Likely: Dermal and Subdermal Reticular Veins and Spider veins) could be considered cosmetic in nature. 

"The decision and the choice of treatment for varicose veins are based on the severity of the venous insufficiency, risk of postoperative complications, and patient preferences. Management options for varicose veins include conservative treatment and surgical intervention. Asymptomatic patients with varicose veins are initially managed with conservative treatment options that include medicine, compression therapy, and lifestyle modifications, while symptomatic patients are suggested to consider surgical options[1] that include endovenous laser ablation (EVLA), radiofrequency ablation (RFA), high ligation and stripping (HL/S) of the incompetent great saphenous vein (GSV), Cure conservatrice et Hemodynamique de l'Insuffisance Veineuse en Ambulatoire (CHIVA), mechanochemical ablation (MOCA), cyanoacrylate embolization (CAE), etc." (Gao et al., 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 outpatient procedure (37785 x1, 37765 x1, 37766 x1, 37799 x1) is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Pain Syndrome
Treatment: Outpatient percutaneous peripheral nerve stimulation
The health plan denied: Outpatient percutaneous peripheral nerve stimulation
The determination is: Upheld

The patient is a female with a medical history of adenocarcinoma status/post neoadjuvant chemotherapy and thoracotomy. She has complaints of lower back and right leg pain. Magnetic resonance imaging (MRI) revealed partial tearing of the hamstring tendon at the ischial tuberosity and findings of early ischiofemoral impingement. Her pain is in the lower back and right buttock/thigh with radiation to the right leg. Her pain level is 10/10 at its worst. She describes her pain as throbbing, tearing, and aching with associated numbness and tingling. The pain is worse with walking and climbing stairs, and improved by right thigh abduction with knee flexing. The physical exam was unremarkable.
At issue is whether percutaneous peripheral nerve stimulation is likely to be more beneficial than any standard treatments.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
The proposed health service or treatment of outpatient percutaneous peripheral nerve stimulation with an out of network provider at an out of network hospital is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has persistent pain consistent with hamstring tendon tear and ischiofemoral impingement. The provider recommended peripheral nerve stimulation (PNS). There are some PNS clinical trials showing long-term pain relief for some chronic pain conditions. However, there are no published clinical trials for pain secondary to hamstring tendon tear and ischiofemoral impingement. Therefore, PNS is unlikely to be more beneficial than any standard treatments for the insured's disease. PNS is considered experimental/investigational when treating this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Pain Syndrome
Treatment: Outpatient percutaneous peripheral nerve stimulation
The health plan denied: Outpatient percutaneous peripheral nerve stimulation
The determination is: Upheld

The patient is a female with lung cancer and chronic pain. The pain is chronic and in her lower back, intractable, and rated 10 out of 10. Prior treatments have included physical therapy, injections, opioids, and multiple other medications. There is a request for peripheral nerve stimulation.
At issue is whether percutaneous peripheral nerve stimulation is likely to be more beneficial than any standard treatments.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
The proposed health service or treatment of outpatient percutaneous peripheral nerve stimulation with an out of network provider at an out of network hospital is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. Peripheral nerve stimulation involves placing a small electrical device (a wire-like electrode) next to one of the peripheral nerves. These are the nerves that are located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles/paresthesias. This modality is not recommended until there is higher quality research, including research on adverse events. The supporting evidence is limited to case reports, retrospective reviews, and small case series, mostly focusing on migraine treatment. Given the lack of support in the medical literature, the requested peripheral nerve stimulator is not appropriate, as it is considered experimental/investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Pain Syndrome
Treatment: Outpatient percutaneous peripheral nerve stimulation
The health plan denied: Outpatient percutaneous peripheral nerve stimulation
The determination is: Upheld

The patient is a female with a history of lung cancer and chronic pain. It is reported that she has chronic low back pain which has been treated with transcutaneous electrical nerve stimulation (TENS) unit, epidural steroid injections, physical therapy, Fentanyl patches, and nonsteroidal anti-inflammatory drugs (NSAIDs). Her treating physician recommended peripheral nerve stimulation.
At issue is whether percutaneous peripheral nerve stimulation is likely to be more beneficial than any standard treatments.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
The proposed health service or treatment of outpatient percutaneous peripheral nerve stimulation with an out of network provider at an out of network hospital would not likely be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Peripheral nerve stimulation (PNS) targets the nerve(s) that transmit pain signals to the brain. PNS involves a tiny implant, a wire about the thickness of a human hair or a group of electrodes about the size of a standard paperclip that delivers electrical impulses, similar to a pacemaker, to the nerve.
The greatest need to further improve this bioelectronic therapy is in researching outcomes to help better understand proper use and patient selection. While several proof-of-concept studies have been published highlighting its use in various types of surgeries, large high-quality randomized controlled trials are still needed.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He was born by spontaneous vaginal delivery. The patient's Apgar scores were 9 at both one and five-minutes of age. 

The neonate was readmitted for a bilirubin of 19.3 milligrams per deciliter (mg/dL). He was afebrile and feeding well. The patient was exclusively breastfed. No risk factors for hyperbilirubinemia were noted. He was started on triple phototherapy and frequent breast feeding was encouraged. At 0112 hours, the bilirubin concentration was 12.1 mg/dL. Phototherapy was discontinued and a rebound bilirubin was obtained at 0121 hours and was 13.1 mg/dL. The patient was discharged home with appropriate follow-up arranged.

The neonate was noted to be of low risk and had no evidence of hemolysis, isoimmunization, etc.

MCG (Milliman Care Guidelines) Health Inpatient & Surgical Care 26th Edition Neonatal Jaundice was provided with the review.

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

The requested health service/treatment of an inpatient stay is not medically necessary for this patient. Although the patient's bilirubin required treatment with phototherapy, that treatment could have been provided at an alternate level of care by home phototherapy. The patient was judged to be low risk, was well appearing, afebrile, and did not require intravenous fluids.

Based on the MCG criteria, Clinical Indications for Admission, a total serum bilirubin (TSB) greater than 20 mg/dL in a lower-risk infant was required for inpatient admission. The patient's bilirubin was 19.3 mg/dL. 

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Heart Failure, Atrial Fibrillation
Treatment: 7 Days times 16 hours of Personal Care Assistance Service (112 hours per week).
The insurer denied the request for 7 Days times 16 hours of Personal Care Assistance Service (112 hours per week).
The health plan's determination is overturned.

The patient is a female with medical history notable for heart failure, sacral ulcers, fall with hip fracture and dementia. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care assistance services. The patient and her care team requested an increase to 16 hours per day, 7 days per week (112 hours per week) and this request was denied by the health plan. This denial is the subject under review.

The patient's physician provided a letter of support for this appeal. The letter states that she requires assistance with activities of daily living including transfers and toileting. The letter also states that she has a history of sacral ulcers and requires assistance with turning in bed. She is unable to ambulate to the toilet without assistance.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives with her son, daughter-in-law, and 3 grandchildren. The patient's son now has a cancer diagnosis and his spouse and family are no longer able to provide informal support for the patient. The patient's cognition was moderately impaired; she was alert to person only. She is not self-directing in her care. She requires total dependence for all instrumental activities of daily living (IADL's). For her activities of daily living (ADL's), she requires total dependence for bathing, dressing lower body and toilet use. She requires maximal assistance for hygiene, dressing upper body, and bed mobility. She requires limited assistance for eating. She is bed-bound and unable to ambulate. She requires a 2 person assist for transfers. She is frequently incontinent of both stool and urine and uses diapers. 

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service of 7 Days times 16 hours of Personal Care Assistance Service (112 hours per week) is medically necessary for this patient. The patient suffers from advanced dementia. She is bed bound and relies on others for all ADL's and IADL's. She requires around the clock care. Her family has been providing informal support, but according to the documentation, their current health issues preclude their ability to do so in the future. The patient's care needs can be expected to be continuous and unscheduled in nature. She will need assistance with changing soiled diapers to prevent infection and/or skin breakdown. She will need assistance with bed mobility to avoid recurrence of pressure ulcers. If the patient's family is no longer able to provide for these needs, then the increase in hours is medically necessary.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary hypertension
Treatment is Uptravi 200 MCG (microgram) tablets
The insurer denied coverage for Uptravi 200 MCG tablets
The denial is overturned.

The patient is an adult who was prescribed the drug Selexipag (Uptravi) for Pulmonary hypertension (HTN). The documents provided for review quantify the number of tablets to be prescribed. No other clinical notes were sent for review.

Selexipag is a Prostacyclin agonist that is approved for the treatment of Pulmonary HTN. The recommendation for starting the drug is to start at an initial dose of 200 micrograms (mcg) twice daily; to be increased by 200mcg twice daily, usually at weekly intervals, to the highest tolerated dose. The maximum dose is 1600 mcg twice daily.

Based on above titration schedule, it is appropriate to dispense 140 Tablets of 200 mcg during the titration phase. Based on the physician's diagnosis of pulmonary hypertension, the number of tablets of Uptravi requested is the appropriate amount.

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 Uptravi 200 MCG tablets is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Liver dysfunction, symptomatic transaminitis.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult female. The request is for coverage of acute inpatient admission. She had been sent to the emergency room because of abnormal liver function tests, nausea, and pruritus. The symptoms began a week prior. She had been using ginseng. The patient was noted to have mild abdominal discomfort, no chest pain, no shortness of breath, and no bleeding. AST (aspartate aminotransferase) was 1039, and ALT (alanine aminotransferase) was 1514. The initial BP (blood pressure) was 164/75, and pulse was 63. Her temperature was normal. Oxygenation was 96%. She was noted to have no acute distress, no abdominal tenderness, and no neurologic deficits. The bilirubin was 3.9, repeat AST (aspartate aminotransferase) was 1143, and ALT (alanine aminotransferase) was 1994. Renal function was normal. CBC (complete blood count) was normal. Prothrombin time normal. Her urine was noted to be with no infection. She was admitted to acute care. The patient's lipase was normal. The impression was hepatitis. An ultrasound of the abdomen showed no bile duct dilation, normal gallbladder, no pancreatic abnormality. She was allowed a diet. She was noted to have no pain and no evidence of liver failure. On Day #2, the patient's BP (blood pressure) was 137/74. Her mental status was normal. Repeat bilirubin decreased to 3.3, and AST (aspartate aminotransferase) was down to 903. She was awake and alert, and in no distress. It was noted that the patient was stable to go home. She was ambulating with a steady gait. The patient's vital signs remained stable. No repeat blood testing was noted. The patient was discharged home.

The Inpatient admission was not medically necessary.

Once the evaluation showed no hepatic encephalopathy, no mental status changes, no bleeding, no vomiting, no intolerance of orals, no unsteady gait, no coagulation deficit, and no renal 
failure, the patient did not require acute care. She could have been treated at a lower level of care. The observation of transaminases does not require acute care and could be performed at a lower level of care. There was no fulminant hepatic failure, no sign of liver decompensation. No ascites, 
no hepatic encephalopathy, no bleeding, no coagulation deficit, no renal failure, no major electrolyte disorder, and no anemia.
No large volume paracentesis was required in this case, nor 
evidence of spontaneous bacterial peritonitis requiring acute care. No evidence of bacterial cholangitis or gallstone pancreatitis was present in this case requiring acute care. The patient's temperature, vital signs, and WBC (white blood count) were all normal, with no identified need for acute hospital care.
No high-risk lesion or bleeding was identified requiring acute care in this case. Therefore, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Coronary Syndrome
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This adult female was sent to the Emergency Department (ED) with an elevated high sensitivity troponin level (480).  The patient was asymptomatic and did not have dyspnea or chest pain.  Past medical history was significant for hypertension, peptic ulcer disease, left ventricular hypertrophy, Chronic Kidney Disease (CKD) with creatinine 1.5 and mild lower extremity swelling.  She was being worked up for amyloidosis as an outpatient. Upon arrival to the hospital vital signs were stable, Blood Pressure 132/64 and Pulse 94. Physical examination demonstrated no abnormalities.  12 lead electrocardiogram (ECG) demonstrated sinus rhythm with an old septal infarct.  Serum blood testing revealed a troponin level of 0.45 and creatinine of 1.5.  The patient was admitted to the hospital. Echocardiogram demonstrated severe left ventricle hypertrophy (LVH) with a left ventricular ejection fraction of 45-50% (percent).  The patient was discharged with a probable diagnosis of amyloidosis and was not diagnosed with myocardial infarction.

This patient presented with no chest pain. Work up for paraproteinemia/amyloidosis that included several outpatient blood tests resulted in an aberrant troponin level that was markedly elevated.  These findings did not correlate with the patient's clinical presentation and were not due to myocardial infarction.  Her pretest probability of coronary artery disease was low. (Reference 1)  Utilizing the HEART score she was considered low risk. (Reference 2)  Utilizing the Thrombolysis In Myocardial Infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  

Based on the above, the insurer's denial must be upheld. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg numbness
Treatment: Ambulatory surgery - procedure to restore blood flow to leg
The insurer denied ambulatory surgery - procedure to restore blood flow to leg.
The determination is overturned.

This is a female patient with peripheral arterial disease who is status/post (s/p) emergent axillobifemoral bypass who presented with left foot and leg numbness for evaluation. The patient also reported symptoms of claudication of the left lower extremity. She denied any rest pain or lower extremity wounds.

A lower extremity arterial duplex exam demonstrated total occlusion of the right superficial femoral artery, right ankle brachial index (ABI) 0.61 consistent with moderate arterial disease and left ABI 0.63 consistent with moderate arterial disease and patent axillofemoral bypass with marked flow disturbance at the left limb anastomosis.

The patient was diagnosed with atherosclerosis of native artery of both legs with rest pain. She was instructed to continue daily aspirin and statin medication and to increase ambulation as tolerated. The patient was seen for follow up of her claudication of the bilateral lower extremities. She was offered treatment of her left lower extremity claudication with an angiogram and intervention. The issue is whether the left lower extremity angiogram with intervention is medically necessary.

The requested health service/treatment of ambulatory surgery - procedure to restore blood flow to the leg is medically necessary for this patient. A computed tomography angiography (CTA) of the abdomen and bilateral lower extremities performed demonstrated 50 percent (%) stenosis of the left femoral bifurcation, 80% stenosis of the left profunda and 90% stenosis of the left common femoral artery. The patient was diagnosed with atherosclerosis of native artery of both lower extremities with intermittent claudication. She has peripheral arterial disease, intermittent claudication that requires treatment. The recommended treatment, angiogram with intervention is the standard of care for the treatment of claudication. The patient will benefit from her treatment. It is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic cholecystitis complicated by a liver abscess.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with an initial diagnosis of chronic cholecystitis complicated by a liver abscess. She was treated with interventional radiology (IR) drainage and intravenous (IV) antibiotics. The drain was removed. She subsequently developed increased gallbladder wall thickness and possible second abscess formation. Given these factors, an elective cholecystectomy with Jackson-Pratt (JP) drain placement esophagogastroduodenoscopy (EGD) and cholangiogram was planned. The procedure was significantly more difficult due to a gangrenous gallbladder and abscess taking 3 times longer than normal. 

The inpatient hospital stay was medically necessary. This was a complicated case. A Cholecystectomy in a diabetic patient with prior percutaneous drainage, prior and current abscess formation, gangrenous gallbladder could be associated with increased complications. The procedure was significantly more difficult due to a gangrenous gallbladder and abscess taking 3 times longer than normal. Therefore, an inpatient admission was appropriate.