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

Diagnosis: Chronic Low Back Pain

Treatment: pain injection (64483 x 1)

The insurer denied coverage for pain injection (64483 x 1)

The denial is overturned

This patient has chronic low back pain and has tried physical therapy (PT) and pain medications for 3 months without improvement. Imaging of the back revealed degenerative disc disease at the lumbar (L) 5- sacral (S) 1 level. The physician recommended a transforaminal epidural steroid injection (TFESI) to treat lower back pain.	

Clinical practice guidelines (1,2) support the performance of Transforaminal Steroid Injection in this patient:

The American Society of Interventional Pain Physicians (ASIPP) guidelines (1) state "the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness." Similarly, the American College of Radiology (ACR) guidelines (2) confirm the indication for an epidural steroid injection in this patient.

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

The insurer's denial of coverage for pain injection (64483 x 1) services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld

The patient is an adult male with a history of hypertension, hyperlipidemia, and diabetes. He presented to the emergency room with complaints of right flank pain. This pain was associated with symptoms that included hematuria, vomiting and diarrhea. On presentation, the patient was afebrile and hemodynamically stable but hypertensive. Examination suggested abdominal and right CVA (costovertebral angle) tenderness. Labs showed a WBC (white blood cell) count of 14.5, creatinine of 1.35, sodium of 131, chloride of 95. CT (computed tomography) scan showed a 4 mm (millimeter) right distal ureteral stone with hydronephrosis. The patient was admitted to the inpatient service, and urology was consulted. The patient was managed with IV (intravenous) fluids, pain meds, antibiotics and tamsulosin. He underwent a cystoscopy with stent placement. There were no intraoperative or postoperative complications. He had a relatively uneventful hospital stay and was discharged home. Medical necessity for the inpatient stay is under review.

The Inpatient admission was not medically necessary.

The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis, as it was done the next day. The procedure that was performed is considered to be a minimally invasive outpatient procedure. As such, in the absence of a "high risk surgical patient," it does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. Observation status for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of gastroesophageal reflux disease (GERD), anxiety, and hiatal hernia who was admitted with complaints of (c/o) dizziness associated with nausea. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), no focal deficits, mild left-sided dysmetria, unable to ambulate due to dizziness. Lab work was notable for mild leukocytosis. Imaging studies included a chest x-ray (CXR) which showed prior granulomatous disease, A computed tomography (CT) scan of the head showed no intracranial abnormality, Magnetic resonance imaging (MRI) of the brain was unremarkable. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with vertigo and was treated with intravenous fluids (IVF), Reglan, anti-emetics, and cardiac monitoring. The emergency department (ED) note documented the desire to discharge home, but the patient was reluctant. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with dizziness and vertigo associated with nausea. The patient did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, or intractable nausea/vomiting. All imaging performed showed no acute intracranial pathology, including a CT scan of the head and MRI of the brain. The patient was treated with intravenous (IV) fluid, an extensive radiological work-up, and meclizine. Given the patient's clinical stability and provided interventions and clinical monitoring, these could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Taltz
The insurer denied coverage for Taltz
The denial is upheld

The patient is an adult with a diagnosis of psoriasis and psoriatic arthritis. The patient has failed numerous topical agents as well as biologics and systemic therapies, including methotrexate, Cosentyx, and Stelara. The request is for Taltz in combination with Otezla. 

Based on the submitted documentation, the patient has failed numerous systemic agents for treatment of psoriasis and psoriatic arthritis. The documentation would support the use of Taltz to treat the existing psoriasis and psoriatic arthritis. However, there are no randomized controlled data to suggest the necessity of continued Otezla use while taking Taltz. 

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 Taltz in addition to Otezla is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a history of a lumbar discectomy. She had a new herniated disc at lumbar vertebrae (L)5-sacral vertebrae (S)1 and was scheduled for an elective discectomy. She presented to the emergency room (ER) with low back and left leg pain. She had no weakness or bowel/bladder changes. She was admitted and given intravenous (IV) Decadron, oral pain medications and muscle relaxants. She was discharged from the hospital.

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

The inpatient stay was not medically necessary. The patient had a normal neurological examination and no bowel or bladder changes. She could have been managed in an outpatient setting with oral Decadron and pain medications. The patient was already set up for surgery the following week, which is also an outpatient procedure. There were no indications or medical issues that justified the patient being admitted to the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: painful flatfeet.
Treatment: Custom Foot Inserts .
The insurer denied Custom Foot Inserts. 
The health plan's determination is upheld. 

The patient is a female who presented complaining of painful flatfeet on both of her feet which is painful with ambulation for the past 3 months. She is complaining of pain on the inside of her feet and has fatigue with ambulation. The patient states that the pain is worse with activity and better with rest. 

After reviewing the submitted records and the current medical literature and standard of care, the custom molded orthotics are not medically necessary for this patient. There is insufficient documentation that the patient has exhausted first line conservative care for an adequate amount of time before proceeding to recommend custom molded orthotics. It appears that the patient had pain for the past 3 months and self treated with some conservative care. On the initial visit, the patient was recommended custom molded orthotics. It does not appear that she has had an adequate course of conservative care including physical therapy, over-the-counter (OTC) inserts, rest, ice, compression, elevation (RICE) treatment, and non-steroidal anti-inflammatory drugs (NSAIDs) that has failed before proceeding to custom molded orthotics. Thus, the custom molded orthotics are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: 64582 (Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array), L8680 (Implantable neurostimulator electrode, each), and L8688 (Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension)
The insurer denied 64582 (Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array), L8680 (Implantable neurostimulator electrode, each), and L8688 (Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension)
The health plan's determination is overturned.

The patient is a male with a history of obstructive sleep apnea. The patient was on continuous positive airway pressure (CPAP) for 5 years (was diagnosed with obstructive sleep apnea (OSA) approximately 10-15 years ago). A home sleep study was performed which showed an apnea hypopnea index (AHI) of 18.6. The lowest 02 (oxygen) saturation was 89%.

Implantation of Hypoglossal Nerve Neurostimulator is medically necessary for this patient.

Current Centers for Medicare and Medicaid Services (CMS) guidelines cover patients with apnea hypopnea index (AHI) 15-65 events per hour. In addition, the Sleep Foundation and the Food and Drug Administration (FDA) have recommended hypoglossal stimulation for patients who have failed CPAP and meet anatomic criteria. This was not based on having an AHI below 20. Furthermore, an elevation of AHI greater than 10% has been associated poor quality of life and health risk.

As the patient has continued to fail CPAP, there are limited options for this patient. If the obstructive sleep apnea (OSA) continues to be untreated, the patient is at significant risk for worsening medical conditions in addition to being at a higher risk of developing cardiopulmonary pathology. Hypoglossal stimulation is the most appropriate option for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer (Non-Hodgkin's lymphoma). 
Treatment: Radiation Therapy. 
The insurer denied: Radiation Therapy. 
The denial is overturned. 

The patient is an adult male with a diagnosis of Mycosis Fungoides s/p (status post) prior radiation to the left groin, right lower lip and right scalp/forehead/eyelid. He presented with symptomatic right shin lesion. Palliative radiation was recommended, and IMRT (Intensity Modulated Radiation Therapy) was requested. 

The proposed treatment of Intensity Modulated Radiation Therapy is "medically necessary". 

For the treatment of cutaneous lesions such as Mycosis Fungoides, the typical radiation technique is with electrons or 3D (three dimensional) conformal radiation therapy. However, this case is an exception. This patient has a very large cutaneous lesion involving the anterior shin. It involves over 180 degrees of the anterior shin and calf area. A 3D (three dimensional) plan was done, but it would treat the entire circumference of the leg, which may result in significant risk of lymphedema. The IMRT (Intensity Modulated Radiation Therapy) plan was able to reduce hot spots and spare part of the skin of the patient's lower leg, which would significantly reduce the risk of lymphedema. The requested IMRT (Intensity Modulated Radiation Therapy) therefore, is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain.
Treatment: Pain Injection.
The insurer denied the request for the pain injection.
The health plan's determination is upheld.

The patient is a female who has complaints of neck pain. The patient is noted to have had prior physical therapy for greater than 3 months and massage therapy with minimal relief for greater than 3 months, as well as chiropractic treatments. The patient had a prior cervical epidural injection with an 80 percent (%) improvement in her function.

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 the pain injection is not medically necessary for this patient. The provider is requesting a cervical epidural steroid injection. It is noted that the patient had a prior cervical epidural steroid injection. There was reported improvement in the usage of her neck and arms. The patient presented for an office visit with a sharp and shooting neck pain radiating into the left upper extremity. The patient reported that the pain interferes with her activities. 

The physical examination demonstrated that her cervical spine range of motion was restricted, with diminished cervical vertebrae (C)6-7 dermatomal distribution. The magnetic resonance imaging (MRI) of the cervical spine showed multilevel degenerative changes. 
More than 12 months have elapsed since the initial injection. There is no support in the clinical policy for continuation of injections beyond 12 months.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite
Treatment: D8080 Braces and D8670 monthly visits
The health plan denied the D8080 braces and D8670 monthly visits as not medically necessary.
The health plan's determination is upheld.

The patient in question is a female with a Class I occlusion (as shown on the cephalometric radiograph) with approximately a 1millimeter (mm) overbite and 2 mm overjet. She has significant maxillary and mandibular crowding. The narrative states she has an anterior crossbite of teeth 6 and 8. She is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21 and 28 to correct her malocclusion.

At issue is the medical necessity for the requested health service/treatment of braces and monthly visits. I uphold, in whole, the health plan's determination of medical necessity.

There is no medical reason to correct her malocclusion with braces. While the patient is crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [1] This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a skeletal Class I occlusion. [2] If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.

The patient is crowded, but no teeth are impacted. Her overbite is 1mm deep and there is no indication of damage to the incisors in the photographs. While the intraoral photos appear to show an anterior crossbite, the patient is not biting down all the way. It also appears she is posturing her jaw forward because the occlusion in the intraoral photos does not match the occlusion in the extraoral smiling photo or the cephalometric radiograph. Neither the extraoral smiling photo and the cephalometric radiograph support a diagnosis of an anterior crossbite.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Xeljanz 10mg twice daily
The insurer denied: Xeljanz 10mg twice daily
The denial is overturned.

The patient is an adult male with moderate to severe ulcerative colitis and psoriasis. He has failed Entyvio and Remicade, and 4 years ago, he started Xeljanz ten milligrams twice daily (BID). Last year, Xeljanz was decreased to five milligrams twice daily. Six months ago, the patient reported increased symptoms, and Xeljanz was increased to ten milligrams twice daily with good results. The physician is requesting to continue Xeljanz ten milligrams twice daily.

The proposed treatment is medically necessary.

Medical literature supports dose intensification of biologics and Janus kinase (JAK) inhibitors in the treatment of moderate to severe ulcerative colitis. Xeljanz has been found to be safe and effective at doses as high as ten milligrams twice daily. This patient has lost response with ongoing symptoms on Xeljanz five milligrams twice daily and is doing well on Xeljanz ten milligrams twice daily. Therefore, continuation of Xeljanz at ten milligrams twice daily is clinically appropriate, accepted standard of care, and medically necessary. Xeljanz 11XR (extended release) is not appropriate, as the patient has failed Xeljanz five milligrams twice daily or ten milligrams daily.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention deficit hyperactivity disorder
Treatment: Vyvanse Cap 30mg (milligrams)
The insurer denied: Vyvanse Cap 30mg (milligrams)
The denial is upheld

The patient is an adult female with diagnosis of attention deficit hyperactivity disorder (ADHD) whose provider is requesting Vyvanse 30 milligram capsules. Outpatient progress note reports that the patient had been previously prescribed Adderall but had been unable to fill her prescription due to a national shortage. As such, alternative medications for treating the patient's attention deficit hyperactivity disorder were discussed and the patient was agreeable to a trial of Vyvanse. She noted that she has previously taken the medication for two years 7 years ago with good benefit and without side effects. She noted significant improvement in her quality of life while on the medication. She stopped the medication due to lack of coverage by her health plan. The plan was to restart Vyvanse 30 milligram capsules in place of Adderall.
Progress notes from 9 years ago indicate that the patient was prescribed Vyvanse and did report that the medication was beneficial to her with regards to treatment of her attention deficit hyperactive disorder symptoms.
At issue is Vyvanse 30 milligram capsules. Coverage was denied by the health plan as not medically necessary based on health plan coverage criteria, which requires trial of or contraindication at least two formulary generics, of which only a trial of Adderall XR was documented. It notes that the patient would need to try or not be able to try either methylphenidate ER or dexmethylphenidate (ER). The decision was appealed by the patient's provide and was upheld by the health plan using the same rationale as previously. The treating provider requested an external review, again stating that the patient has had a good response to Vyvanse in the past. 

The proposed treatment is not medically necessary.

Review of the medical literature concludes that there is little difference among the individual attention deficit hyperactivity disorder pharmacotherapies with regards to effectiveness, tolerability, and safety. Coverage was denied by the health plan because the patient had only tried one of three available preferred formulary medications for attention deficit hyperactivity disorder, which was Adderall XR, and health plan policy states that the patient must have tried or have a contraindication to at least two of these. She has not previously tried either of the remaining formulary medications, which are methylphenidate ER or dexmethylphenidate ER, and she does not have a documented contraindication to either of these. The medical literature indicates that either of these medications should be comparable to the requested Vyvanse with regards to effectiveness, tolerability, and safety. The definition of medical necessity generally includes that a treatment must not be provided solely for the convenience of the patient or the provider. Since Vyvanse does not fit this definition in this case, it is not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, gastroesophageal reflux disease (GERD), macular degeneration, legal blindness, osteoarthritis, hypotension, malignant neoplasm, and pressure ulcers

Treatment: Personal care services 24 hours a day, 7 days a week, for a total of 168 hours per week (split shift)

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

The denial is overturned.

 
This is an elderly legally blind female with metastatic cancer and dementia. She is currently a resident in a skilled nursing facility (SNF) and wishes to return to her private residence. The insurer approved personal care services (PCS) 8 hours/day, 7 days/week (total 56 hours/week). The request is for PCS 24 hours/day, 7 days/week (168 hours/ week-split shift).

According to the Uniform Assessment System (UAS) report the patient's cognition is described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." She is totally dependent for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing, lower body dressing and toilet transfer/use. She is occasionally incontinent of bladder and frequently incontinent of bowel. Extensive assistance is needed for personal hygiene, upper body dressing and bed mobility. She is totally dependent for locomotion and ambulation. She frequently falls, recently fractured her left femur and developed a pressure ulcer. She is essentially bed/wheelchair bound. She requires frequent bed repositioning for skin breakdown prevention; particularly given her propensity for skin break down as well as bowel and bladder incontinence. The combination of the patient's clinical condition, cognitive deficits and functional decline are at a level and unpredictable as to require PCS 24 hours/day, 7 days/week (split shift) particularly as she transitions from the nursing facility to her private residence. As for a live-in, the personal care aide (PCA) is unlikely capable of providing for the patient's functional needs with the ability to obtain uninterrupted 5 hours of sleep.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care services (PCS) 24 hours a day, 7 days a week, for a total of 168 hours per week (split shift) is substantiated.