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

Diagnosis: Paroxysmal supraventricular tachycardia /atrial fibrillation

Treatment: Implantable loop recorder (ILR)

The insurer denied coverage for implantable loop recorder (ILR)

The denial is overturned.

This is a male with a history of non-obstructive atherosclerotic coronary artery disease (CAD), hypertension (HTN) and obstructive sleep apnea (OSA) who presented to his physician with palpitations. He was previously treated with beta blocker therapy, but he noted that his symptoms were exacerbated following COVID-19 (2019 Novel coronavirus) infection. He reported that his heart rate would jump into the 180 bpm (beats per minute) range with minimal exertion. Physical examination revealed no abnormalities. Echocardiography revealed a structurally normal heart with a left ventricular ejection fraction (LVEF) of 61% (percent). A Zio patch mobile telemetry monitor placed from, demonstrated no episodes of tachycardia and an average heart rate of 66 bpm. Of note, the patient reported significant rash and skin irritation that resulted in early termination of the mobile telemetry study. Palpitations persisted and the patient was referred to a cardiac electrophysiologist that recommended implantation of a loop recorder (ILR) in order to make a diagnosis. The differential diagnosis included inappropriate sinus tachycardia, supraventricular tachycardia (SVT), atrial fibrillation (AF), ventricular ectopy or palpitations not related to tachycardia.

This patient suffers from palpitations and obstructive sleep apnea. Attempts to correlate symptoms with heart rhythm utilizing an ambulatory ECG (electrocardiogram) monitor for 11 days (Zio patch) were not successful. Moreover, the patient terminated the study prematurely due to skin rash and irritation. Although extended external loop recorders have been shown to demonstrate adequate diagnostic yield (1), this patient cannot tolerate such a device for an extended period. 

Additionally, this patient suffers from obstructive sleep apnea and is at risk for developing atrial fibrillation and other forms of supraventricular tachycardia (2). The diagnostic yield of implantable loop recorders in patients with palpitations is in the 80-90% range (3). Moreover, ILRs demonstrated a six-fold increased detection rate of Atrial Fibrillation compared to external ambulatory monitoring (4). Detection of AF in this individual with a CHADSVASC (congestive heart failure, high blood pressure, age, diabetes, previous stroke/clot, vascular disease, age, and sex) risk score of 2 would require initiation of oral anticoagulant therapy to prevent stroke.

In conclusion, loop recorder implantation is medically necessary in this case, where ambulatory monitoring failed to detect arrhythmia in a patient with HTN, OSA and probable paroxysmal SVT or even atrial fibrillation.

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

The insurer's denial of coverage for an implantable loop recorder is reversed. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Surgery (ablation with imaging guidance), Pre-service.

The insurer denied the Surgery (ablation with imaging guidance), Pre-service.  The denial is upheld. 

The patient is a female with a diagnosis of fibroid uterus requesting coverage for transcervical uterine fibroid ablation with US (ultrasound) guidance, radiofrequency.

The patient's ultrasound showed three fibroids less than five cm (centimeters) in size. The patient's diagnoses are anemia, pelvic pain, and fibroids.

No, the health plan should not cover the requested ablation with imaging guidance.
The Sonata System combines intrauterine ultrasound (IUUS) with radiofrequency (RF) ablation in a single handpiece. Sonata is suitable in an inpatient or outpatient setting, and is intended for diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding.  The Sonata system is FDA (United States Food and Drug Administration)-approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids.  Symptomatic improvement is observed within the first three months post-procedure, and this improvement has been maintained at least through 24 to 36 months of follow-up.

However, there are more established procedures available, such as a hysterectomy or myomectomy. These procedures would be considered standard of care over treatment with the Sonata system.

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

The patient may be appropriate for a myomectomy or a hysterectomy which would lead to an immediate improvement in her condition.  Those procedures for the management of fibroids have been used, are well-established, and are standard of care.

Based on the above, the requested service is not medically appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Surgery (ablation with imaging guidance), Pre-service.

The insurer denied the Surgery (ablation with imaging guidance), Pre-service.  The denial is upheld. 

The patient is a female G4P2 (four pregnancies; two births) with dysmenorrhea, heavy menses, pelvic pain from a fibroid uterus.  She has had two prior cesarean sections.  She had a robotic myomectomy. She has tried and failed the levonorgestrel-containing IUD (intrauterine device).

Ultrasound revealed enlarged uterus measuring 11.3 by 4.3 by 7.3 cm (centimeters) with three fibroids and a malpositioned IUD (intrauterine device).  The IUD (intrauterine device) was removed, and at follow up, the patient's bleeding had improved.  The plan is for transcervical radioablation of the fibroids with Sonata and another IUD (intrauterine device).

No, the health plan should not cover the ablation with imaging guidance.

According to the American College of Obstetrics and Gynecology, "There are a variety of treatment options for leiomyomas, including expectant, medical, interventional, and surgical therapies. Although evidence exists regarding outcomes with specific therapies, comparative effectiveness data are lacking for leiomyoma management options. When considering treatment options, patient-specific symptoms and severity should be addressed. If a patient describes symptoms that are neither severe, nor debilitating, expectant management may be appropriate. Medical treatments primarily address bleeding symptoms. Procedural interventions and surgical approaches treat bulk symptoms by decreasing uterine mass."

The ACOG (American College of Obstetrics and Gynecology) reports that, "Radiofrequency ablation (RFA) can be delivered by a laparoscopic, transvaginal, or transcervical approach, using ultrasound guidance to induce coagulative necrosis in targeted uterine leiomyomas. All of the approaches are similarly effective in reducing uterine leiomyoma volume and in improving quality of life metrics, but the laparoscopic approach has been studied the most rigorously. Although RFA (Radiofrequency ablation) is a reasonable option to consider for the treatment of symptomatic uterine leiomyomas, access to this technology is currently limited."

In summary, there are not any large randomized controlled trials or large observational trials that provide evidence that this procedure is better than the alternative options.  There are also no data to support use of this procedure as being effective and safe long term in patients with symptomatic uterine myomas as compared to other alternatives.  This procedure is also not endorsed by the American College of Obstetrics and Gynecology, who provides the guidelines for OB/GYNs (obstetricians/gynecologists) in the United States.  Therefore, this is not considered a standard of medical practice at this time.  Therefore, it should not be covered by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke.
Treatment inpatient emergency admission.
The insurer denied coverage for inpatient emergency admission.
The denial is upheld.

The patient is a male with a past medical history of bariatric surgery. The patient arrived at the emergency room (ER) with complaints of nausea and an elevated blood pressure since the night before. The patient complained of weakness to the left shoulder and change in appetite associated with nausea. The patient denied shortness of breath, chest pain, loss of consciousness, vomiting, abdominal pain, fever, chills, recent falls, strenuous lifting, headache, or blurred vision. The patient also endorsed intermittent nausea and lightheadedness since he awoke from sleep. On physical examination, cranial nerves II (2) through XII (12) were grossly intact.  There was left shoulder and left arm weakness. There was an inability to abduct the left shoulder (1/5) and extend the elbow (2/5) and L (left) wrist (3/5). Sensation was preserved throughout and the patient's gait was normal.

Neurology saw the patient in the ER and recommended admission for MRI (magnetic resonance imaging) to rule out a central cause of the patient's left shoulder weakness. Aspirin and atorvastatin were given. The patient's admitting diagnosis was stroke, rule out and further imaging work-up. The CT (computed tomography) scan was normal.  The MRI was negative for acute compression fracture or significant cervical canal stenosis. The MRI/MRA (magnetic resonance angiography) revealed no acute infarct. Brachial neuritis came into the differential due to the negative findings on the diagnostic studies. The patient was stabilized and discharged. The patient was to be scheduled for outpatient rehabilitation and an EMG (electromyography) study.

The patient could have been worked up in the ER with MRI/MRA and stroke would have been ruled out. Proximal shoulder weakness is not consistent with acute stroke because stroke typically causes more distal extremity weakness. The care provided, including diagnostic studies and specialty consultation with Neurology could have been performed in the ER and at an observation level of care. 

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

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

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

Diagnosis: Knee pain
Treatment: Knee Injection Services (hyaluronan) (J7323)
The insurer denied the Knee Injection Services (hyaluronan) (J7323)
The denial is upheld.

This is a male with right knee pain. He noted previous surgery times two (x2) and had cortisone injections. His physical examination was significant for tenderness. His x-rays showed osteoarthritis. He was provided with a cortisone injection. He returned a few weeks later with continued pains. His physician recommended bilateral knee arthoplasties in the future. He also recommended Euflexxia injections.  The patient received injections approximately two months after evaluation to both knees.

No, the proposed treatment is not medically necessary.
The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis (OA) if all other courses failed prior to surgery.  However, the recommendations for use of viscosupplementation had changed.  


A review of the Clinical Practice Guideline (CPG) by the American Academy of Orthopedic Surgeons (AAOS)  cites: 

The OA (osteoarthritis) knee treatment CPG (Clinical Practice Guideline) contains one significant recommendation change from the CPG (Clinical Practice Guideline), and this is with regard to the issue of viscosupplementation. The OA (osteoarthritis) knee CPG (Clinical Practice Guideline) included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG (Clinical Practice Guideline).

The second edition CPG (Clinical Practice Guideline) recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA (osteoarthritis) of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's (Clinical Practice Guideline) best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA (hyaluronic acid) preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS (American Academy of Orthopedic Surgeons) CPGs ((Clinical Practice Guideline)," AAOS (American Academy of Orthopedic Surgeons) Now.)

The Orthopedic group reports "strongly do not recommend use".

Additional references and expert opinion do not support benefit. (See references)

A meta analysis was completed. There were several references reviewed. The evidence based criteria did not support use.  (See references)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain, nausea, and vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a woman. Her medical and surgical histories were negative.

The patient presented to an emergency department with a one-day history of epigastric pain, nausea, and vomiting. Her vitals were temperature 98.8, pulse 83, blood pressure 144/82, respirations 19, oxygenation 99%. Physical examination demonstrated tenderness to palpation of the epigastrium and right upper quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 14.84. Abdominal ultrasound demonstrated, "Cholelithiasis without sonographic stigmata of acute cholecystitis." HIDA (hepatobiliary iminodiacetic acid) scan demonstrated acute cholecystitis. The patient was admitted at an acute inpatient level of care. She was made nil per os [NPO], and she was provided with intravenous fluids and antibiotics.

The patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated. The following day, having returned to her baseline health and function, the patient was discharged home in good and stable condition with prescriptions for oral analgesics and outpatient surgical follow-up.

No, the Inpatient admission was not medically necessary.
According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [1]. Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission.

Based on the provided medical documentation and in accordance with national guidelines, for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial Fibrillation.
Treatment: Endoscopy ablation (procedure to restore normal heart rhythm).
The insurer denied endoscopy ablation (procedure to restore normal heart rhythm).
The determination is overturned.

The patient has a past medical history of hypertension and paroxysmal atrial fibrillation (PAF). He was previously treated one year prior with radiofrequency ablation therapy (RFA). The patient continues to have PAF with symptoms of continued shortness of breath associated with his episodes of atrial fibrillation (AF). He is currently on medical therapy with Amlodipine, Carvedilol, Apixaban and Aspirin. He is seen in consult for minimally invasive atrial fibrillation hybrid ablation (Convergant Procedure). At issue is whether the endoscopy ablation (procedure to restore normal heart rhythm) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The requested procedure is likely to be more beneficial than any standard treatment or treatments. In this patient with long-standing and recalcitrant atrial fibrillation (AF) that has persisted despite adequate medical therapy and endocardial ablation, a hybrid epicardial and endocardial approach would be indicated. (1,2). Kress et al. show a success rate of an AF-free survival of 72% versus 51% in patients that underwent endocardial ablation alone. (2) This patient has long-standing atrial fibrillation with the presence for over multiple years. (3). Additionally, surgical indication for stand alone atrial fibrillation includes patients with symptomatic AF despite therapy with one class I or class III anti-arrhythmic agent. (3) This patient meets criteria for standalone therapy with the additional indication of continued AF after previous RFA. Hybrid endocardial and epicardial ablative therapy additionally has shown effectiveness of freedom from AF and reduction in repeat procedures required for AF that recurs after stand-alone endocardial ablation. (1,2,4)
The procedure is not only indicated for the patient but is of clinical benefit. Additionally, this procedure has a documented safety profile that in a younger patient may save him multiple years of morbidity associated with his atrial fibrillation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial Fibrillation.
Treatment: Endoscopy ablation (procedure to restore normal heart rhythm).
The insurer denied endoscopy ablation (procedure to restore normal heart rhythm).
The determination is overturned.

The patient has a history of atrial fibrillation, status/post (s/p) catheter-based ablation one year prior. The atrial fibrillation recurred. He had cardioversion with recurrent atrial fibrillation and was symptomatic on medical therapy. He is currently in recurrent, paroxysmal atrial fibrillation. The health plan denied endoscopy ablation (procedure to restore normal heart rhythm) and at issue is whether this is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The combined procedure, endoscopic pulmonary vein ablation combined with a catheter-based ablation is likely to be more beneficial to a repeat ablation alone or utilizing additional second line medical therapies in this patient who failed prior ablation and is on medical therapy with symptomatic atrial arrythmias. The therapy has been shown to be more effective but is associated with higher risk of complication as well. Short- and medium-term evidence is favorable and is recommended by the Society of Thoracic Surgeons' Guidelines for the treatment of atrial fibrillation. Informed consent is essential as is the combined modes of endoscopic epicardiac ablation as well as repeat endo-cardiac ablation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Knee Meniscus Tear

Treatment: Outpatient procedure 27447 x [times] 1, knee replacement surgery

The insurer denied coverage for outpatient procedure 27447 x 1, knee replacement surgery.

The denial is upheld.

This is a female with a history of a left knee meniscus tear. She had a medial meniscal repair of the left knee. 

An operative report was submitted which described arthritis to the medial compartment and tears to menisci. The physician performed partial meniscectomies and debrided the medial compartment. The facts were several arthroscopic procedures were performed. The procedure code of 27447 would not be applicable. This code is for a knee arthroplasty (i.e. total knee replacement). The physician performed 29881, 29882 and 29879. 

Arthroscopy (code of 27447) was not performed. Therefore, the insurer acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the outpatient procedure 27447 x 1, knee replacement surgery, is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines

Treatment Reyvow

The insurer denied coverage for Reyvow.

The denial is overturned.

The patient has a past medical history of migraines, multiple sclerosis, stroke, gastroesophageal reflux disease, hypercholesterolemia, osteoporosis, and thyroid nodules.  The patient was currently utilizing amitriptyline 50 mg (milligram) nightly.  The patient denied side effects.  The patient was having almost daily headaches.  The patient was taking Fioricet and BC powder for the headaches.  As per the progress note, the patient took Fioricet about 45 pills/month although she did not take them every day. She is currently on amitriptyline 50mg nightly.   The patient had daily headaches and migraines once a week.  The associated symptoms included phonophobia, photophobia, and nausea.  The patient had tried Emgality.  The patient noted the gabapentin and propranolol did not work.  The Fioricet helped.  The provider recommended Ubrelvy at onset of headache and again 2 hours later if needed.  The patient was to stop Fioricet.  The patient was not able to take triptans. 

The appeal letter noted that the patient has tried and failed all the formulary alternatives. She has tried and failed Nurtec ODT (rimegepant), Ubrelvy (ubrogepant), zembrace symtouch, and zomig nasal spray. She cannot take triptans because of a history of stroke. It should also be noted that she is taking fluoxetine and keppra and trazadone.

In a note, the plan included amitriptyline, Emgality (galcenezumab-gnlm) monthly injections and Ubrelvy for immediate treatment.  Patient is to stop Fioricet. 

The formulary medications except for Nurtec are likely to cause the patient an adverse reaction. All of the other medications are triptans, which would put her at risk for a stroke. Therefore, all of these formulary meds must be avoided. Nurtec is the only safe alternative on the formulary, and she has already tried and failed Nurtec.

The requested drug Reyvow should be more effective because it has a different mechanism of action and formulation. As stated by Up to Date "Reyvow-Lasmiditan is a selective serotonin 1F (protein receptor) agonist that lacks vasoconstrictor activity and therefore can be used for patients with relative contraindications to triptans due to cardiovascular risk factors."

The insurer's denial of coverage for Formulary Exception for Reyvow is reversed.