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

Diagnosis: Psychogenic non epileptic seizures, diabetes, hypertension and deep vein thrombosis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with past medical history of psychogenic non epileptic seizures, diabetes, hypertension and deep vein thrombosis status post inferior venous cava filter who developed a generalized seizure requiring midazolam by the emergency medical services. It was reported that patient was non-compliant with her medications. It was noted that patient also had left hemiparesis and was treated with intravenous (IV) levetiracetam and intravenous fluids. She was noted to have intermittent shaking. She returned back to baseline between each episode. Given the left sided weakness, there was concern for Todd paralysis versus a stroke. Magnetic resonance image (MRI) was negative for a stroke. Neurology thought that her seizures were due to psychogenic non epileptic seizures and recommended an electroencephalogram as an outpatient. Once there were no longer seizure episodes she was discharged. The inpatient admission was determined as not medically necessary as services could have been provided on observation status.

No, the inpatient admission was not medically necessary.
The patient had seizures that were thought to be psychogenic non-epileptic seizures with resulting Todd paralysis. She returned to baseline between each episode. Observation status can be done for up to 48 hours and the patient had no needs including a continuous electroencephalogram that would require hospitalization past the 48 hour period. Moreover a magnetic resonance image (MRI) which was done to rule out a stroke can be done in 24 hours. The one time where a hospitalization admission is indicated is with that of status epilepticus which is defined as seizures without a return to baseline which was not the case with this patient. Furthermore the neurology team decided to defer an electroencephalogram to be done as an outpatient.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
All of the appropriate workup could be done on an observational status and can be done in less than 48 hours especially when it was thought that the diagnosis was that of psychogenic non-epileptic seizures.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: ST-Segment Elevation Myocardial Infarction (STEMI).
Treatment: Automatic External Defibrillator.
The insurer denied the Automatic External Defibrillator.
The denial is upheld.

The patient is a male for which a wearable cardiac defibrillator is under review. There was history of diabetes and hyperlipidemia. He developed an anterior wall myocardial infarction. There was successful percutaneous intervention of the culprit left anterior descending (LAD). The left ventricular ejection fraction (LVEF) was 35%. Medical therapy, including a beta blocker, and angiotensin-converting-enzyme (ACE) inhibitor, was initiated.

No, the health plan should not cover the prposed treatment.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
Indications for a temporary wearable defibrillator are similar to those for an automatic implantable cardioverter defibrillator (AICD). Those with an ischemic cardiomyopathy status post revascularization and where medical therapy has been initiated, as in this case, have a potentially reversible cardiomyopathy.   An automatic implantable cardioverter defibrillator (AICD) at the time of the diagnosis and without an optimal trial of medical therapy (i.e. 40 to 90 days ) and subsequent documentation of a persistent severe cardiomyopathy (left ventricular ejection fraction [LVEF] less than 35%), is not medically necessary.   Neither an automatic implantable cardioverter defibrillator (AICD) or a wearable defibrillator (Zoll Life Vest) at the time of the cardiomyopathy diagnosis, compared to optimal medical therapy for 40 to 90 days and an automatic implantable cardioverter defibrillator (AICD) if the left ventricular ejection fraction (LVEF) remains at or less than 35%,  has been established as standard of care towards improved cardiac outcomes.  Therefor the Zoll Life Vest is considered not medically indicated and not more beneficial than standards of care in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: ST-Segment Elevation Myocardial Infarction (STEMI).
Treatment: Automatic External Defibrillator.
The insurer denied the Automatic External Defibrillator.
The denial is overturned.

The patient is a male who presented with ST-Segment Elevation Myocardial Infarction (STEMI).  He was immediately sent to the catheterization lab, and underwent successful stenting of 100% occluded left anterior descending (LAD). Post infarct echocardiogram showed ejection fraction (EF) of 30% to 35%.  He had a brief, non sustained ventricular tachycardia (VT) post procedure. Otherwise no evidence of ventricular tachycardia (VT) or malignant arrhythmia was seen. A Wearable Cardioverter Defibrillator (WCD) was ordered. The patient was discharged after an uncomplicated three night stay. Monthly follow ups were unremarkable and repeat echocardiogram showed an ejection fraction (EF) of 57%.

Yes, the health plan should cover the proposed treatment.
While there has been little evidence that wearable cardioverter defibrillators (WCD) are beneficial during the "waiting period" for both nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy, there is a subset where benefit is documented. Post acute myocardial infarction (MI), wearable cardioverter defibrillator (WCD) is recommended during the immediate 40 days post myocardial infarction (MI). There has been shown a survival benefit.  "Accordingly, in the most recent ACC/AHA/HRS (American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society) guideline, the use of a WCD (wearable cardioverter defibrillators) after AMI (acute myocardial infarction) in patients with an LVEF (left ventricular ejection fraction) 35% has been given a IIb recommendation ."

Per guidelines, including Centers for Medicare and Medicaid Services (CMS), this patient is appropriate for wearable cardioverter defibrillator (WCD) for 40 days. When repeat echocardiogram showed an ejection fraction (EF) of 57%, it was no longer needed.

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.
The most recent American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Rhythm Society (HRS) guideline, the use of a wearable cardioverter defibrillator (WCD) after acute myocardial infarction (AMI) in patients with an left ventricular ejection fraction (LVEF) of 35% has been given a IIb recommendation. A subset in the VEST trial did show benefit of wearable cardioverter defibrillator (WCD) over medical therapy in post myocardial infarct.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back and Neck Pain. 
Treatment: 22899 unlisted procedure, spine (Intracept), C9752 and C9753 (Destruction of intraosseous basivertebral nerve). 

The insurer denied coverage for 22899 unlisted procedure, spine (Intracept), C9752 and C9753. 

The denial is upheld. 

This patient has chronic low back pain. She takes Tylenol, Percocet, Zanaflex, and has used nonsteroidal anti-inflammatory drugs (NSAID) for pain. She has tried Physical therapy, Home Exercise, radiofrequency ablation (RFA) of her lumbar facet joints, Epidural steroid injections, Heat/Cold without significant pain relief. Her magnetic resonance imaging (MRI) shows Modic changes at lumbar (L) level (L3-L4 and L4-L5).  She is morbidly obese with body mass index [BMI] 42. The request is for ablation of basivertebral nerves.

Fischgrund and colleagues (1) published a double-blind, sham controlled RCT [random controlled trial] evaluating the Intracept system and RF [radiofrequency] ablation of the Basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF [radio frequency] probe was activated and the temperature at the tip was maintained at 85Celscius for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100-point scale) and a minimum VAS [visual analog scale] of 4 cm (centimeter) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13% [percent]) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance. 

The publications to date have been company sponsored and had methodology flaws. UptoDate (3) has evaluated this procedure and there are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches. The adverse risks are not fully known. 

The carrier's denial of 22899 unlisted procedure, spine (Intracept), C9752 and C9753should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of Factor V Leiden
Treatment: Factor V Leiden Genetic Testing (81241-F5)
The insurer denied the Factor V Leiden Genetic Testing (81241-F5)
The denial is overturned.

This patient has no personal history of thromboembolism, thrombophilia, deep vein thrombosis, or coagulopathy. He has not had an activated protein C level. No other laboratory or clinical information is included in the review materials. However, a paternal aunt had right peroneal vein venous thrombosis and an unprovoked left calf vein thrombosis. This paternal aunt is a factor five Leiden heterozygotes/carrier. An uncle has factor five Leiden deficiency as well but no history of clots. Her father carries the factor five Leiden mutation and has had venous clots before age 50, as does the maternal grandmother and her father's two siblings, who all have a history of venous clots before age 50. A paternal great aunt had deep vein thrombosis (DVT) at age 46 and then multiple venous thromboembolisms after recent spinal surgery at unknown age. The attending physician has requested factor five Leiden testing in him to determine his risk of deep vein thrombosis/coagulopathy in the future during surgery or other circumstances disposing him to pathological venous thrombosis.

Yes, the health plan should cover the proposed treatment.
The markedly positive paternal family history for the common factor five Leiden mutation/variant and venous thromboembolism before age 50 renders molecular genetic testing for factor five Leiden deficiency in this patient as clinically appropriate.

Yes, the requested health service is more beneficial than any standard treatment for the insured's condition.
Factor five Leiden deficiency is the most common inherited disorder predisposing to venous thromboembolism and thrombosis. The association with and causation of factor five Leiden mutations/variants with an increased risk for venous thromboembolism is well established in the medical literature, is consistently and well supported by authoritative, peer-reviewed, published medical literature, as well as policy statements from the American College of Medical Genetics. 

Therefore, given this patient's markedly positive paternal family history for venous thromboembolism with onset before age 50 and the relevant medical literature cited below, molecular genetic testing for factor five Leiden deficiency in him is medically appropriate and clinically appropriate and not experimental, investigational, or unproven in his family history context.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of Factor V Leiden
Treatment: Factor V Leiden Genetic Testing (81241-F5)
The insurer denied the Factor V Leiden Genetic Testing (81241-F5)
The denial is upheld.

The patient is a male teen that was tested for Factor V Leiden because of family history and physician recommendation. The paternal grandmother has the disease, the father and two of his siblings have the disease, and all but the father have history of blood clots. His father had formal testing revealing one copy of the Factor V Leiden (R506Q) gene mutation.

No, the health plan should not cover the proposed treatment.
Genotypic testing in the absence of abnormal phenotypic testing was not medically appropriate or consistent with the current standard of care.

No, the requested health service is not more beneficial than any standard treatment for the insured's condition or disease.

Per plan language, Factor V Leiden testing is warranted when a first-degree blood relative is positive for the disease in conjunction with a patient's abnormal activated protein C resistance assay. 

Per the American College of Medical Genetics, testing for Factor V Leiden mutation may be indicated for relatives of individuals known to have the mutation because it may be useful information for pregnancy and oral contraceptive recommendations. The College concludes, "when relatives of individuals known to have factor V Leiden are tested, the DNA method is recommended." However, this guideline is about twenty years old and not reflective of current lab capabilities and practices. 

Based on current studies, "phenotypic testing showed a high level of sensitivity, specificity, and other biostatistical values compared with genotypic testing" (Murphy & Sabath) suggesting that the APC resistance assay is an appropriate first-line test with confirmatory DNA (Deoxyribonucleic Acid) testing if warranted.

While testing for this patient was reasonable and appropriate given the strong family history of Factor V Leiden and the potential impact on potential future surgical complications, the health plan's requirement for APC (Activated Protein C) resistance testing was reasonable, consistent with the current standard of care, and not fulfilled prior to genetic testing.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Venous Insufficiency (chronic) (Peripheral). 
Treatment: 36465 - Varithena - Right/Left (RT/LT) Injection Of Non-Compounded Foam Sclerosant With Ultrasound Compression Maneuvers To Guide Dispersion Of The Injectable, inclusive Of All Imaging Guidance And Monitoring; Single Incompetent Extremity Truncal Vein (e.g. great saphenous vein, accessory saphenous vein). 

The insurer denied the 36465 - Varithena - RT/LT Injection Of Non-Compounded Foam Sclerosant With Ultrasound Compression Maneuvers To Guide Dispersion Of The Injectable, inclusive Of All Imaging Guidance And Monitoring; Single Incompetent Extremity Truncal Vein (e.g. great saphenous vein, accessory saphenous vein). 

The denial is upheld. 

The patient is a woman who presented with bilateral varicose vein symptoms. She had one episode of redness of the left lower leg. Reflux testing showed bilateral great saphenous vein (GSV) dilation and reflux and probably left leg superficial phlebitis. The provider proposed to do both radiofrequency ablation (RFA) and Varithena sclerosant therapy for both GSVs (great saphenous veins). The patient was approved for bilateral GSV (great saphenous vein) RFA (radiofrequency ablation), but Varithena therapy was denied. 

No, the health plan should not cover the requested health service. 

The patient is a woman who presented with bilateral varicose vein symptoms. She had one episode of redness of the left lower leg. Reflux testing showed bilateral great saphenous vein (GSV) dilation and reflux and probably left leg superficial phlebitis. The provider proposed to do both radiofrequency ablation (RFA) and Varithena sclerosant therapy for both GSVs (great saphenous veins). The patient was approved for bilateral GSV (great saphenous vein) RFA (radiofrequency ablation), but Varithena therapy was denied. 

Widely accepted published criteria will be used to determine the appropriateness of the procedure. 

Under widely accepted criteria [1-8], endovenous ablation of an axial saphenous vein is medically appropriate when appropriate clinical criteria are satisfied. RFA (radiofrequency ablation) is considered the current gold standard because of high efficacy and durability, but in some instances, Varithena is appropriate as a substitute for RFA (radiofrequency ablation) [8]. Examples of cases where Varithena is appropriate are tortuous or extra-fascial target vein. 

However, there are no data to support doing both RFA (radiofrequency ablation) and Varithena. The provider has given literature references describing the safety and efficacy of Varithena, but these studies did not use Varithena as a second treatment after RFA (radiofrequency ablation). They studied Varithena as a standalone treatment. To reiterate, there is no clinical literature to support combined treatment with RFA (radiofrequency ablation) and Varithena. 

No, the requested health service is not more beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Venous Insufficiency (chronic) (Peripheral). 
Treatment: 36465 - Varithena - Right/Left (RT/LT) Injection Of Non-Compounded Foam Sclerosant With Ultrasound Compression Maneuvers To Guide Dispersion Of The Injectable, inclusive Of All Imaging Guidance And Monitoring; Single Incompetent Extremity Truncal Vein (e.g. great saphenous vein, accessory saphenous vein). 

The insurer denied the 36465 - Varithena - RT/LT Injection Of Non-Compounded Foam Sclerosant With Ultrasound Compression Maneuvers To Guide Dispersion Of The Injectable, inclusive Of All Imaging Guidance And Monitoring; Single Incompetent Extremity Truncal Vein (e.g. great saphenous vein, accessory saphenous vein). 

The denial is upheld. 

The patient is a female with venous insufficiency. The patient has tried support stockings and has leg swelling with heaviness. The patient has no complications associated with varicosities and venous insufficiency. 

No, the health plan should not cover the requested health service. 

The patient is a female with venous disease, according to the provider's office note. The patient has tried three months of conservative therapy. The patient has leg heaviness and swelling that interferes with activities of daily living. Her physical exam shows varicosities with edema. No ulceration or phlebitis is evidenced. Venous duplex scan showed bilateral great saphenous vein reflux. The patient underwent endovenous ablation of the bilateral great saphenous veins. 

The health plan should not cover the requested health service for 36465 (Varithena) for bilateral lower extremity, because the patient had symptomatic varicosities and venous insufficiency involving bilateral lower extremity, and the patient already underwent endovenous ablation of the bilateral great saphenous veins. There is no additional clinical note and follow up exam to show that the patient is still symptomatic secondary to the varicosities despite having had endovenous ablation of the bilateral great saphenous veins. The patient has no active ulceration, bleeding or phlebitis. 

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. The patient already had treatment of the refluxing bilateral great saphenous veins.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders: Autoimmune Disease 
Treatment: Pharmacy/Prescription Drugs 
The insurer denied Xeljanz XR 11mg. 
The denial is upheld in whole. 

The patient is a male with a diagnosis of ankylosing spondylitis. Human leukocyte antigen (HLA) B27 was reported to be positive. The patient has a history of inflammatory back pain, sacroiliitis and syndesmophyte. The patient has had previous inadequate response to oral nonsteroidal anti-inflammatory drugs (NSAIDs), sulfasalazine, Enbrel, Humira and Cosentyx. The patient's physician ordered Xeljanz extended release (XR) 11 milligrams (mg) for the treatment of ankylosing spondylitis.
At issue is the medical necessity of Xeljanz XR 11mg. 

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

The requested health service/treatment of Xeljanz XR 11 mg is not medically necessary for this patient. 

Xeljanz XR or any other Janus kinase (JAK) inhibitor is not yet approved by the United States Food and Drug Administration (FDA) for the treatment of ankylosing spondylitis. The packaging insert of Xeljanz XR does not include ankylosing spondylitis for treatment. In addition, the 2019 American College of Rheumatology (ACR) guidelines for the treatment of ankylosing spondylitis prefer the use of tumor necrosis factor (TNF) inhibitors or interleukin (IL) 17 inhibitors over Xeljanz XR. 

Therefore, the requested health service/treatment of Xeljanz XR 11 mg is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis

Treatment: Hospital admission

The insurer is denied coverage for hospital admission.

The denial is overturned. 

This female patient has a history of eczema and bronchiolitis.

The patient needed inpatient level care since there was profound hypoxia and tachypnea at the time of presentation. The primary care physician was concerned enough to send the patient to ED. In the ED, she was given rescue meds such as bolus Decadron and massive amount of bronchodilators. The patient also needed continuous albuterol and oxygen. When patients receive continuous Beta agonist, they are at risk for electrolyte abnormalities such as hypokalemia and acidosis. Also, hypotension from massive beta agonist has been reported along with electrocardiogram (EKG) abnormalities. The patient needed high level of care. Most common cause of out of hospital cardiac arrest is respiratory causes. She also needed continuous IV fluids and boluses. 

The patient needed inpatient level of care due to risk of hemodynamic instability and risk of worsening respiratory status that could pose significant morbidity and mortality.

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 hospital admission is overturned.  The medical necessity is substantiated.