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

Diagnosis: Ligamentum Hypertrophy. 

Treatment: Current procedural terminology (CPT code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure]. 

The insurer denied coverage for current procedural terminology (CPT) code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure]. 

The denial is overturned. 

This is the case of a male patient with chronic low back pain. He has documented lumbar spinal stenosis (LSS) with neurogenic claudication. He has had physical therapy and epidural steroid injection without pain relief. The request is for the minimally invasive lumbar decompression (MILD) procedure. 

Staats et al (1) conducted a robust trial of the MILD procedure with 2 year follow-up and concluded: "MILD showed excellent long-term durability, and there was no evidence of spinal instability through 2-year follow-up. Reoperation and spinal fracture rates are lower, and safety is higher for MILD versus other lumbar spine interventions, including interspinous spacers, surgical decompression, and spinal fusion. Given the minimally invasive nature of this procedure, its robust success rate, and durability of outcomes, MILD is an excellent choice for first-line therapy for select patients with central spinal stenosis suffering from neurogenic claudication symptoms with hypertrophic ligamentum flavum." 

Jain et al (2) summarized the indications and contra-indications of the MILD procedure: 

"To summarize, all of the following inclusion criteria must be met for the patient to be a candidate for mild procedure: 

- Symptomatic LSS (i.e., presence of neurogenic claudication); 
- Confirmation of stenosis on imaging; 
- Ligamentum flavum hypertrophy (LFH) [ligamentum flavum (LF)>2.5 mm]. 

This patient meets all of the indications and has no contra-indications to the procedure. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The requested MILD surgery does not need final approval from the appropriate regulatory bodies for this diagnosis. This patient is a reasonable candidate for the requested MILD surgery. Based on the lack of improvement from prior treatments, the requested MILD surgery is the best available treatment for this patient at this time. The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 
 
The carrier's denial of CPT code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure] should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident for which she was hospitalized, left foot fracture. 

Treatment: Personal care worker (PCW) services of 8 hours per day, 7 days per week for a total of 56 hours per week. 

The insurer denied coverage for personal care worker (PCW) services of 8 hours per day, 7 days per week for a total of 56 hours per week. 

The denial is overturned. 

The patient has a past medical history of cerebrovascular accident for which she was hospitalized, left foot fracture, uncorrected vision of "count fingers" in the right eye, 20/70 vision in the left eye, with poor peripheral vision, depression, essential hypertension, hyperlipidemia, paroxysmal atrial fibrillation, presence of a cardiac pacemaker, polyneuropathy, presence of a left artificial knee joint, spinal stenosis, and osteoarthritis of the left knee.  The patient's daughter indicated that the patient was unable to complete activities of daily living on her own due to a recent stroke.  The patient was unable to get to the bathroom herself.  The patient suffered from ulcerative colitis.  There were days when she frequented the bathroom.  The New York State Department of Health's Uniform Assessment System noted that the patient usually understood.  The patient had severe difficulty with vision but her eyes appeared to follow objects.  She saw light only.  She was totally dependent for meal preparation.  She was maximal assist for medications and finances as well as housework.  She needed extensive assistance with phone use, transportation, bathing, dressing her upper body, bed mobility, walking, toilet transfer, and toilet use.  The patient used an assistive device for locomotion.  The patient had a fall within the last 30 days.  An increase to personal care worker (PCW) services of 8 hours/day 7 days/week for a total of 56 hours/week was being requested. 

The requested Personal Care Worker (PCW) Services of 8 hours per day, 7 days per week for a total of 56 hours per week is considered medically necessary for this patient. 

This patient has multiple medical problems and has suffered a recent stroke. This has caused further impairment to mobility and greater dependence on others. She also has significantly impaired vision and now needs assistance with all her activities of daily living (ADL). She was reported to have fallen recently and continues to be at high risk for falls and other adverse events which may complicate the falls. She is at risk for frequent hospitalizations due to increased frailty. She would benefit from increased PCW of 8 hrs. a day, 7 days a week. 

Therefore, the denial of requested Personal Care Worker (PCW) Services of 8 hours per day, 7 days per week for a total of 56 hours per week should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  dementia.
Treatment: level 2 personal care services, per 15 minutes 24 hour(s) per day (split-shift).
The insurer is denied coverage for level 2 personal care services, per 15 minutes 24 hour(s) per day (split-shift).
The denial is overturned. 

This female patient has a history of Parkinson's disease, dementia, coronary heart disease and aspiration pneumonia

The patient is unable to ambulate independently even with walker, and has balance and strength issues due to vertigo, tremors, and neuropathy. She requires assistance with all ADLs, even at night and is at high-risk of fall, especially if she tries to get up at night without assistance. This is a risk given her transient confusion/dementia. A live-in 24-hour assistance would not be appropriate since the patient requires frequent nighttime hours as well. The 24-hour aide would not be able to rest/sleep and would be awake for most of the 24 hours. Therefore, the level 2 personal care services are appropriate.

"Caregivers also have a high prevalence of sleep disturbance. Prior reviews indicate that as many as 50-70% of caregivers for a family member with dementia experience sleep disturbance [6] and approximately 40% of caregivers for a family member with cancer reported sleep problems [7]. The most common types of sleep problems in caregivers of adults with cancer are short sleep duration and nocturnal awakenings, resulting in daytime dysfunction [7]. Sleep disturbance contributes to adverse health outcomes and poor quality of life for caregivers [6, 8]. However, sleep disturbance in this population is under-addressed and undertreated [6]." (Byun et al 2016)

"It is important to understand which caregiving aspect causes most distress to informal caregivers of people with Parkinson's. Findings from the meta-analysis [8] indicate that physiological motor symptoms and dependence in ADLs have moderate correlation with caregiver distress. Declining cognitive function and higher level of the patient's depression level have small to moderate relationship to caregiver strain. It is the caregiving intensity (hours spent on caregiving activities) which is strongly associated with the caregiver burden." (Bhimani 2014)

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

The carrier's denial of coverage for the level 2 personal care services, per 15 minutes 24 hour(s) per day (split-shift) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seronegative Rheumatoid Arthritis

Treatment Humira 40 milligrams (mg)

The insurer denied coverage for Humira 40 milligrams (mg).

The denial is overturned.

This case involves a female who has recently been diagnosed with seronegative Rheumatoid Arthritis.  The documentation indicated she has been receiving treatment for inflammatory polyarthritis.  She has been utilizing Plaquenil without relief.  Humira has been recommended according to the physician as the next appropriate treatment.  She was seen complaining of pain as well as swelling and stiffness to left hand and wrist.  She has a prior elevated erythrocyte sedimentation rate (ESR)  and c-reactive protein (CRP).  She has also undergone an ultrasound showing tenosynovitis and synovial proliferation.  She has been treated in the past with prednisone which helped.  She has been maintained on hydroxychloroquine.  She noted about a 35% (percent) reduction in pain.  She continues however to have considerable symptoms.  The physical exam revealed mild tenderness in few metacarpophalangeal (MCP) joints to the left hand and slight pain on flexion and extension of the wrist.  There was no synovitis or tenderness to the right hand/wrist.  The physician indicated she had a mild elevation of inflammatory markers and inflammatory changes on ultrasound.  She did have some improvement in symptoms with hydroxychloroquine however continues to have significant pain as well as swelling and stiffness in left hand and wrist.  It was recommended she attempt treatment with additional medication.  It was recommended that she attempt an additional disease-modifying antirheumatic drugs (DMARD) with low-dose methotrexate in addition to hydroxychloroquine to see if this may provide additional relief.  It was recommended she begin methotrexate.  The request has been received for Humira as she called the office shortly after initiation of methotrexate complaining of severe nausea as well as headaches.

Based on the medical record available, this is a patient who has seronegative arthritis who failed Plaquenil and could not tolerate methotrexate.  Current medical practice is to now go to a biologic.  Rein et al. note that on failure of methotrexate, a biologic DMARD is favored.  There is no set sequence and a TNF [tumor necrosis factor] is appropriate in this setting. They note that Humira had a clinical efficacy response of 63% comparing favorably to other agents.  The requested Humira is an appropriate option given its history of safety and efficacy for years. The health plan did not act reasonably with sound medical judgment in the best interest of the patient

Based on the above, the medical necessity for the Humira 40 milligrams (mg) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Pancreatitis. 

Treatment: Inpatient level of care. 

The insurer denied coverage for inpatient level of care. 

The denial is upheld. 

The patient has chronic pancreatitis and presents with epigastric pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. A dilated common bile duct was found. An endoscopy showed gastric varices. There was also a chronic splenic vein thrombosis. An endoscopic ultrasound (EUS) showed a normal common bile duct. The patient had been admitted to the hospital every month for the past few months. He had been referred to a pancreas specialist as an outpatient. He was treated with a proton pump inhibitor (PPI) for gastritis. The Eliquis was stopped due to extensive gastric varices. 

Clinical indications for admission for pancreatitis (M-250) include having acute pancreatitis. This patient had chronic pancreatitis, not acute pancreatitis. Other indications include infection. Severe pain not responding to analgesics, hemodynamic instability, hypoxemia, acute renal failure, as an inability to maintain oral hydration. The patient did not have these conditions. 

Clinical indications for admission undiagnosed abdominal pain (M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, or the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

This patient had chronic pancreatitis and chronic abdominal pains. He required an endoscopic workup but was stable for an outpatient workup. Pain control could have been given as an outpatient. Treatment for gastritis could also have been given as an outpatient. He did not meet Milliman Care Guideline (MCG) Criteria for admission for pancreatitis or undiagnosed abdominal pain. The denial is upheld. 

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

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

Diagnosis: Hip Fracture 

Treatment: inpatient admission

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

This female patient has a history of hypertension and sickle cell trait

Milliman Care Guidelines (MCG) recommends inpatient admission for fractures to include vertebral fracture requiring observation for instability or neurologic compromise; Compartment syndrome (proven or cannot be ruled out during observation care); Major injury requiring inpatient stabilization such as traction initiation or external fixation before internal fixation or closure of complex or open fracture; Major injury requiring inpatient treatment after observation care (as appropriate); Limb-threatening injury; Injury with suspicion of abuse or neglect (eg, child, dependent elderly); or severe pain requiring acute inpatient management. 

In this case the patient was transferred from another facility due to right hip fracture.  The patient denied any trauma, injury, or recent fall.  CT scan of the pelvis completed on revealed comminuted fracture of the right greater trochanter.  The patient was recommended for admission to trauma surgery with hematology consultation.  Orthopedic notes indicated no acute orthopedic intervention was necessary at that time and the patient was recommended for outpatient follow-up. Given the lack of surgical intervention, consults and work up could have been completed in an observational level of care. Criteria for inpatient admission was not met. The health plan acted reasonably with sound medical judgment.

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

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

Diagnosis: Rheumatoid Arthritis
Treatment: Humira 40MG
The insurer denied the Humira 40MG
The denial is overturned.

This patient is a female with history of rheumatoid arthritis. The patient has previously tried and failed conventional disease modifying antirheumatic drugs (DMARDs) methotrexate, leflunomide and sulfasalazine. Humira was initially denied due to the patient not having tried and failed methotrexate at a dose of 20 mg (milligrams) or greater weekly for at least three months.

Yes, the requested treatment with Humira is medically necessary.
The patient was initiated on methotrexate prior but was unable to tolerate it. She was also initiated on other conventional DMARDs (disease-modifying antirheumatic drugs), including sulfasalazine and leflunomide. The patient has a history of positive HLA B27 (human leukocyte antigen B27) and some questionable axial involvement.

The patient has a diagnosis of seronegative rheumatoid arthritis but has a history of HLA B27 (human leukocyte antigen B27) positivity, which takes and questions the possibility of axial spondyloarthropathy.  MRI (magnetic resonance imaging) did not show evidence of sacroiliitis.  The patient has previously tried and failed now three conventional DMARDs (disease-modifying antirheumatic drugs), including methotrexate, leflunomide and sulfasalazine.  Appeal letter and clinical notes do state that the patient did not tolerate methotrexate and leflunomide.  The patient also has elevated liver function tests on lab evaluation, which would make methotrexate contraindicated due to hepatotoxicity.  Therefore the American College of Rheumatology guidelines for the treatment of rheumatoid arthritis would suggest that a biologic DMARD (disease-modifying antirheumatic drug) be now used for treatment of rheumatoid arthritis.  Therefore, Humira would be a reasonable next step for this patient.  Therefore, the health plan did not act reasonably with sound medical judgment, and in the best interest of the patient, as the requested Humira is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This case involves a male who presented to the hospital complaining of chest pain.  The documentation does indicate he has a past history of alcohol abuse as well as diabetes, cocaine abuse, hypertension, hyperlipidemia, and coronary artery disease.  The documentation indicated he had left-sided chest pain radiating to the left arm.  He did indicate he took aspirin as soon as his chest pain started.  The documentation indicated he had no other associated symptoms.  Physical examination revealed the patient was calm and cooperative.  He was ambulatory with a steady gait.  There was no evidence of tremor.  His blood pressure was 145/93 with a pulse of 60 bpm (beats per minute).  Oxygen saturation was 99% (percent) on room air.  The patient did have evidence of leg swelling.  The recommendation was made for laboratory diagnostic studies.  An electrocardiogram (EKG) revealed a heart rate of 85 bpm with inverted T (intervals on EKG) waves.  The physician indicated given a history of prior condition with EKG changes the recommendation was made to undergo a cardiology consultation.  It was also recommended he be placed on continuous cardiac monitoring and receive IV (intravenous) analgesia for pain.  The physician indicated multiple nurses tried to establish intravenous (IV) access as well as draw blood however, this was unsuccessful.  The physician also indicated after many attempts over the course of a half an hour to place a sonogram guided IV a successful attempt to place a line was achieved.  The physician indicated he had complaints of being tremulous and felt he was going into withdrawal from alcohol.  He did receive Librium and Ativan was ordered.  He did complain of discomfort to the left arm.  The documentation indicated per nurse notes that the patient had complaints of unbearable pain and thoughts of suicide.  The nurse informed the patient that the physician ordered pain medication and the patient was placed on constant observation.  The documentation indicated laboratory studies reviewed and the patient did refuse a heparin drip for the possibility of acute coronary syndrome.  He was admitted and continued with treatment.  Psychiatry was consulted due to the suicidal statement and the onset of pain.  The documentation indicated he continued with additional treatment and monitoring.  There were no further significant adverse events.  The patient ultimately signed out AMA (against medical advice).

The patient had atypical chest pain with no objective markers of an acute coronary syndrome. In addition, the patient left AMA. Psychiatry consulted and noted no suicidal ideation, plan or intention. Therefore, a lower level of care in this clinical scenario was appropriate. An inpatient admission is not medically necessary the health plan acted reasonably with sound medical judgment.

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

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

This patient is a male with comorbidities of chronic venous insufficiency, obesity, coronary artery disease, coronary artery bypass grafting (CABG), atrial fibrillation, and hypertension.  He had diagnostic studies completed including labs (including complete blood count [CBC], comprehensive metabolic panel [CMP], creatine kinase [CK], Troponin and blood cultures).  There is no past treatment and response noted.  

The patient's current complaints consisted of confusion, weakness of legs, falling, and pain in the left hip region. Current objective findings revealed fever of 102F (Fahrenheit), tachycardia 110-120 beats per minute, persistent, white blood cell (WBC) count 14,000/dL, creatinine (Cr) 1.7 (baseline less than 1.4), troponin 0.567, glucose 260 milligrams per deciliter (mg/dL), creatine kinase (CK) 3772, lactate 2.78 (normal less than 2), sinus tachycardia with first degree atrioventricular block, creatine kinase (myocardial band [MB]) 9.4, elevated.

The health plan denied the admission since the patient was deemed to not have mental status change, failure of outpatient antibiotics, bacteremia, limb or life threatening infection or immune compromise.

Yes, the proposed inpatient admission was medically necessary.
The Infectious Diseases Society of America (IDSA) guidelines recommend hospitalization for individuals with systemic inflammatory response syndrome (SIRS) and mental status change. This patient did not merely have cellulitis. He also had sepsis as defined by elevated creatinine relative to baseline, elevated lactic acid level and altered mental status with fall. Further, he had rhabdomyolysis with acute kidney injury and denial letter is incorrect in stating that the patient did not have acute kidney injury. The patient also had evidence of demand ischemia related cardiac injury as indicated by the elevated troponin, creatine kinase (CK), and creatine kinase myocardial band (CK-MB). The creatine kinase level actually went up the second day of admission to the 5000s and then began to come down. The patient had fever, leukocytosis and persistent tachycardia at rest on presentation, clearly indicating that he had systemic inflammatory response. As such, his illness was life threatening, contrary to the claim made in the denial letter.

The patient has sepsis, systemic inflammatory response, lactic acidosis, acute kidney injury, confusion and altered mental status, with cardiac injury manifested by troponin elevation and rhabdomyolysis indicated by elevation in creatine kinase (CK) The presence of acute kidney injury also indicates rhabdomyolysis and its effect on the kidney. The patient required inpatient admission according to the Infectious Diseases Society of America guidelines. The patient required intravenous antibiotics and intravenous fluids with lab monitoring daily and clinical assessment on a frequent basis. The presence of elevated creatine kinase (CK) can also suggest pyomyositis and necrotizing infection.