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

Diagnosis: Back Pain
Treatment: Trigger Point Injection (20553x1) Pre-service
The insurer denied the Trigger Point Injection (20553x1) Pre-service.
The denial is overturned. 

The patient is a male with a history of chronic neck, thoracic and low back pain.  He has undergone extensive conservative treatment in the form of physical therapy, chiropractic care, acupuncture, home exercise, medications including non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and opiate medications.  He has had epidural steroid injections in the past without any significant benefit.  Trigger point injections have been recommended.

Yes, the proposed Trigger Point Injection (20553x1) is medically necessary.

The procedure is medically necessary.  The patient has failed all forms of conservative treatment.  Physical exam does show a trigger point, tight band with radiation.  Trigger point injections are a commonly used technique for muscular pain when conservative treatment has been exhausted.  The procedure is minimally invasive, low risk and has been shown to be effective in some situations.  Given that the patient has failed all conservative treatment and has isolated trigger point injections which are palpable on physical exam, the requested procedure is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Open left knee surgical wound
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

This patient is a female who underwent a left total knee replacement. She fell getting out of the shower. She reported a laceration to her knee. Her wound had opened. She was able to ambulate. She was found to have full range of motion with six-centimeter (6cm) wound "dehiscence." X-rays were satisfactory. The patient was admitted to hospital for "washout and closure" the next day. The procedure was completed and discharge.

Yes, the inpatient hospital admission was medically necessary.

The medical record demonstrated an emergent condition which required surgical management. A complication occurred secondary to fall. The patient was found to have an open knee joint after total knee replacement (TKR). The operative record described deep soft tissues were disrupted with large entry into joint. The condition is serious and requires operative management as provided. There is a high chance of infection which can result in catastrophic long standing problem. Irrigation, debridement AND layered closure was required. Antibiotic coverage should also be given. It would be important to have close observation of wound to determine viability of skin. These services were complex and required admission and length of stay (this was not a simple laceration with wound closure). Criteria were met for an emergent condition with post surgical complication requiring surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Dupixent 300MG/2ML SC SOPN
The insurer denied the Dupixent 300MG/2ML SC SOPN
The denial is overturned. 

The patient is a male with severe persistent asthma. He has been prescribed dupixent.

Yes, Dupixent 300MG/2ML SC SOPN is medically necessary.

The clinical documentations provided suggests that patient has been compliant with ICS (inhaled corticosteroids)/LABA (long-acting beta agonists) as well as other asthma maintenance medications. Patient has had recent asthma exacerbation requiring steroids and has had multiple cycles of prednisone use in the past 12 months. 
Dupilumab has been shown to increase lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma irrespective of baseline eosinophil count. Thus, addition to inhaled corticosteroids plus long-acting 2-agonist therapy could improve the lives of patients with uncontrolled persistent asthma compared with standard therapy alone. To date, there is the strong need to compare the efficacy across the monoclonal antibodies (mAbs) approved to treat severe asthma. All the investigated mAbs were more effective than placebo in reducing the risk of exacerbation and improving lung function. Dupilumab showed a general superiority compared to the other mAbs, as it significantly reduced the risk of exacerbation vs. omalizumab, and significantly improved FEV1 (forced expiratory volume) when compared to omalizumab, mepolizumab, and benralizumab. Since the patient's asthma is inadequately controlled with current treatments, the addition of dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End-Stage Right knee arthritis.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This is a female patient with a past medical history of  diabetes, hypothyroidism, obstructive sleep apnea on continuous positive airway pressure, morbid obesity with a body mass index of 40.51, depression, renal cancer and atrial fibrillation, which is treated with Eliquis. The patient was admitted for a scheduled right total knee arthroplasty, due to a diagnosis of end stage right knee arthritis.  Of note, the patient had a left total knee replacement a few months prior.  The patient tolerated the procedure well and without complications.  Post-operatively, the patient received pain management, intravenous antibiotics, physical therapy and occupational therapy.  The patient was discharged in stable condition with medications for pain management and instructions to follow up with Orthopedic Surgery.

The medical records demonstrate a non-complicated post-surgical course.  The underlying comorbidities were taken into consideration.  The clinical record showed ability to tolerate oral pain medications.  The patient was able to walk 50 feet with a walker.  Her hematocrit was stable, i.e. no bleeding.  There were no problems with her wound, i.e. no evidence of infection. She did not require additional treatment, imaging nor other services for underlying medical problems.  There were no extenuating circumstances to warrant the acute level of care. 

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

The inpatient admission is not considered medically necessary for this patient.

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

Diagnosis: Bilateral upper eyelid dermatochalasis.
Treatment: Browpexy.

The insurer denied coverage for Browpexy.  The denial is overturned.

This is a female patient with bilateral upper eyelid dermatochalasis who presented to the ophthalmologist's office for an evaluation.  The patient's visual acuities were 20/25 in the right eye (OD) and 20/40 in the left eye (OS).  The patient's exam showed 2+ dermatochalasis OD and 3+ dermatochalasis OS with rash above the left upper lid. 

The patient presented for follow-up.  Her visual acuities were 20/30 in both eyes.  Her exam showed brow ptosis bilaterally, 2+ dermatochalasis OD and 3+ dermatochalasis OS. The patient's visual field testing was performed a few days after the follow-up visit, and it showed superior field defect bilaterally that improved with taping of the eyelids. The patient's frontal and lateral photos showed bilateral redundant upper eyelid skin with extension of the upper lid over the lashes and affecting the visual axis.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The history, clinical exam and testing support that the browpexy procedure is medically necessary and within standard of care.

The bilateral browpexy procedure is medically necessary and within standard of care for this patient.  Frontal and lateral photos document redundant upper eyelid skin with clear extension of the upper lid over the lashes and affecting the visual axis.  Visual field testing confirms functional superior field defects in both eyes that improved with taping of the eyelids.  In addition, the patient reported her eyelids affecting her vision and her eyelids feeling heavy.

As per literature review, bilateral browpexy procedure is considered medically necessary and within standard of care for this patient. This procedure is intended to improve the patient's vision and function.  The patient's clinical exam showed bilateral upper eyelid dermatochalasis with hooding, and the patient's frontal and lateral external photographs documented excess upper eyelid skin affecting the visual axis, and the patient's visual field testing showed a superior field obstruction. In addition, the patient reported her eyelids affecting her vision and her eyelids feeling heavy. All of these clinical findings support the medical necessity of this patient's requested procedure.

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

The insurer's denial of coverage for the Pre-Service Request for a Browpexy should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Epilepsy.
Treatment: Empatica Embrace 2 Smart Watch (wearable device for seizure tracking).

The insurer denied the Empatica Embrace 2 Smart Watch (wearable device for seizure tracking).  The denial is overturned.

The patient is a female child with medical history significant for benign rolandic epilepsy, with new onset seizure. At that time, she was under treatment for otitis media. The seizure was described as tonic clonic movements lasting several minutes, eyes rolled back, with grunting noises. She fell onto the floor and was unable to move. She had urinary incontinence and vomited while in the ED (emergency department), also reporting subsequent headache. Since that time, she had several episodes of not being able to move or speak at night with or without body shaking, each lasting several minutes. Increased nocturnal salivation has also been reported. The initial EEG (electroencephalogram) was unremarkable, although there were periods during drowsiness and sleep that were suspicious for partially expressed epileptiform discharge activity. MRI (magnetic resonance image) and 24-hour EEG (electroencephalogram) were subsequently ordered. She has since been diagnosed with benign rolandic epilepsy treated with night-time benzodiazepine. Because of the nature of her seizure activity, occurring during sleep or upon arousal from sleep, the Empatica Embrace system has been prescribed to alert family upon seizure activity and prevent potential complications.

Yes, the health plan should cover the Empatica Embrace 2 Smart Watch (wearable device for seizure tracking).

Yes, the Empatica Embrace 2 Smart Watch (wearable device for seizure tracking) is likely to be more beneficial.

The Empatica Embrace system is medically appropriate for this preteen with nocturnal generalized epilepsy.

Benign rolandic epilepsy is the most common form of childhood epilepsy characterized by generalized typically night-time tonic-clonic seizures arising from the rolandic part of the brain. It is considered "benign" because many children eventually outgrow the condition. There may be a genetic component because it tends to run in families. In additional to seizures, this condition may also be associated with migraines and behavioral or learning differences.

Sudden unexpected death in epilepsy (SUDEP) is rare in children but is the leading cause of death related to epilepsy in young adults. The concern in this particular patient is that her seizure activity is exclusive to night when she is isolated in her room and her family is unable to witness what is happening. By detecting seizure activity, the Empatica Embrace system would alert the family and allow for intervention. This child has already fallen off of furniture, increasing the likelihood of injury should she fall out of bed. She also has increased salivation and has had postictal vomiting, raising concern for aspiration and potentially even suffocation. The Empatica Embrace system is medically appropriate in this situation, consistent with the current standard of care, and likely to be more beneficial than any available standard management.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Epilepsy.
Treatment: Empatica Embrace 2 Smart Watch (wearable device for seizure tracking).

The insurer denied the Empatica Embrace 2 Smart Watch (wearable device for seizure tracking).  The denial is upheld. 

The patient is a female with a diagnosis of benign rolandic epilepsy, and she has generalized convulsive seizures.  According to the patient's provider, the patient began with nocturnal convulsive seizures, which were associated with excessive drooling and also causing her to fall out of bed on at least one occasion. Therefore, it is important that family members have a way of being alerted to these seizures, so they can intervene. The provider recommends a wearable device for seizure tracking (Empatica Embrace 2 Smart Watch) for monitoring and alerting to generalized tonic-clonic seizures. According to the provider, this device is cleared by the FDA (United States Food and Drug Administration) for this purpose.

No, the health plan should not cover the Empatica Embrace 2 Smart Watch (wearable device for seizure tracking).

No, the Empatica Embrace 2 Smart Watch (wearable device for seizure tracking) is not likely to be more beneficial.

There is no evidence that seizure monitoring devices improve the patient's safety and treatment outcomes.

Benign rolandic epilepsy is considered to be on the mild spectrum of the epilepsy syndrome, manifesting with occasional brief convulsions. Trauma or injury are extremely uncommon in this epilepsy syndrome cases, since seizures are typically nocturnal and occur in patient's own bed. There is no evidence in the published medical literature that unattended rolandic seizures jeopardize the patient in any way or lead to negative consequences, such as trauma or aspiration. At the same time, seizure monitoring devices, such as Embrace detect seizures when it already reaches convulsive phase, and by themselves do not prevent the patient from falling out of bed. There is no evidence in the published practice guidelines or peer-reviewed medical literature to indicate that seizure monitoring devices in benign rolandic epilepsy improve treatment outcomes or promote patient's safety. This treatment is not generally accepted in pediatric neurology community for the cases of benign rolandic epilepsy and is not considered as appropriate. Therefore, the device requested is not medically appropriate and should not be covered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder pain. 
Treatment: Trigger Point Injections. 

The insurer denied Trigger Point Injections. 
The health plan's determination is upheld. 

The patient is a female with a history chronic left shoulder pain. She was involved in a motor vehicle accident and underwent surgery and continued to have pain and were treated with physical therapy (PT) and injections. She was diagnosed with AC (acromioclavicular) joint instability. X-rays revealed calcific tendinitis. A magnetic resonance imaging (MRI) of the left shoulder was negative. However, a note from the provider states "MRI of the left shoulder shows partial thickness tear of her supraspinatus tendon. There is also signs of arthrosis within the AC joint. Fluid in biceps sheath." 
Under review is the medical necessity of Outpatient Surgery/Professional Services: Trigger Point Injections. 

Trigger point injections are not medically necessary for this patient. The medical records and appeal documentation do not demonstrate that prior injections resulted in over 50% improvement for at least 6 weeks. 

Regarding trigger point injections ...In the diagnostic or stabilization phase, patients may receive injections at intervals of no sooner than one week and preferably two weeks. The number of trigger injections should be limited to no more than four (4) times per year for the diagnostic or stabilization phase. 
In the treatment or therapeutic phase, injections should continue only if the previous diagnostic injections provided pain relief and the frequency should be two (2) months or longer between each injection. The previous injections should have provided at least >50% relief of pain for a period of at least six weeks. The injections should be repeated only as necessary and these should be limited to a maximum of six (6) times for local anesthetic and steroid injections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services (All). 
The insurer denied Vein surgery (Endoluminal Ablation of Varicose Veins) for medical necessity. 
The denial was overturned in whole.  

The patient is a female with symptomatic right lower extremity varicose veins. The patient has been a patient of the vascular surgery practice. The patient complains of aching, heaviness and swelling of her right leg. The patient works as a teacher and is on her feet all day. The patient has been using compression stockings with no improvement in her symptoms.
A venous duplex exam performed, demonstrated right great saphenous vein reflux. The patient was offered right great saphenous vein radiofrequency ablation and right lower extremity phlebectomy.
At issue is the medical necessity of Vein surgery (Endoluminal Ablation of Varicose Veins).

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

The requested health service/treatment of Vein surgery (Endoluminal Ablation of Varicose Veins) is medically necessary for this patient.
The patient has symptomatic right lower extremity varicose veins and venous insufficiency. She has been using compression stockings. The requested treatment, of vein surgery (endoluminal ablation of varicose veins), is medically necessary. The patient has symptomatic varicose veins and venous insufficiency, and radiofrequency ablation is the standard of care for the treatment of venous insufficiency and symptomatic varicose veins. Generally, a patient will benefit from this treatment plan.
Therefore, the Vein surgery (Endoluminal Ablation of Varicose Veins) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Short Stature
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug Nutropin. 
The health plan's determination is overturned.

This is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her growth hormone (GH) stimulation test with glucagon and L-dopa (levodopa) peaked at 12 and 5.5, respectively. Her height velocity is reported to be 3.5 centimeter (cm)/year. Her Insulin-like Growth Factor 1 (IGF1) was 192 (80-400). 

At issue is the medical necessity of the requested prescription medication Nutropin.

The health plan's determination of medical necessity is overturned in whole, as the request is medically necessary.

Yes. The peer reviewed literature, including consensus clinical guidelines, randomized controlled trials are summarized below:

Idiopathic Short stature

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient had a pretreatment height less than or equal to -2.25 standard deviations (SD). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria.

The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute prostatitis.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a male patient with history of benign prostatic hypertrophy (BPH). The patient presented to the Emergency Room (ER) with a two day history of fever, chills, fatigue. His temperature was 38.4 Celsius (C). The patient had been treated for acute prostatitis just prior to admission and completed a course of Bactrim. Testicular vital signs revealed 1.3 centimeter (cm) epididymal cyst, small bilateral hydroceles. The patient was admitted to medicine. A fever to 39 C was treated with Tylenol. Computed tomography (CT) scan of the abdomen was unremarkable. The patient had an Interventional Radiology (IR) procedure, a guided lymph node biopsy. Prostate specific antigen (PSA) was 16.1. The patient was treated with Levofloxacin, developed a rash after the second dose, and treated with Benadryl. Blood cultures returned negative at 48 hours. The patient was deemed stable for discharge home after a period of medical stability. 

The insurer has denied coverage for the inpatient admission as not medically necessary. They noted the patient's clinical course. He was noted to have a fever, lymphadenopathy, night sweats but he remained hemodynamically stable.  

Per InterQual (2019) Adult Acute Infection: Sepsis - criteria for Prostatitis, the patient fails to meet clinical indications for admission to inpatient care. IR guided lymph node biopsy is an outpatient procedure. The patient also fails to meet criteria for admission per Milliman Care Guidelines (MCG) Health 24th Edition UTI [Urinary Tract Infection] (no hemodynamic instability, bacteremia, new onset coagulopathy, altered mental states, etc.).

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered to be medically necessary for this patient. 

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

Diagnosis: Brief Left-Sided Weakness. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who presented with the complaint of transient left-sided weakness and slurred speech. At presentation, the patient's neurological examination and vital signs were normal. He was admitted and neuro-imaging was negative for acute stroke. Echocardiogram showed 20% ejection fraction. 

The acute inpatient admission was not medically necessary. 

The patient presented with transient weakness that had resolved and was admitted for transient ischemic attack (TIA). The clinical presentation, neurological examination, history and vital signs did not warrant inpatient level of admission based on current risk stratification guidelines. The diagnostic studies, neurological evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.