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

Diagnosis: Chest pain, assaulted
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a female with asthma, prior Brazilian butt lift and liposuction, and dilation and curettage (D&C) who presented to the emergency room (ER) after being repeatedly kicked and hit by her boyfriend. Vitals with a blood pressure (BP) 143/92, heart rate (HR) 103, respiratory rate (RR) 26, saturating 100% on room air. On physical exam, left periorbital contusion, left lower chest wall tenderness, mild spinal tenderness, decreased range of motion of hands and shoulders secondary to contusions. The patient is having significant pain in her head, chest, back and shortness of breath. Focused Assessment with Sonography for Trauma (FAST) scan positive for pneumothorax. Labs remarkable for white blood cell (WBC) of 13 and an aspartate aminotransferase (AST) of 220 and an alanine aminotransferase (ALT) 109, alcohol level was not checked. Chest x-ray with possible 7th rib fracture on the left and subcutaneous emphysema. Computed tomography (CT) of the head showed left periorbital swelling. CT of the spine was without fracture. CT of the chest with prior old rib fractures on the right (9,10) and left (6,7,8) with a new 5th rib fracture on the left, small anterior and lateral pneumothorax on the left. The patient was admitted for monitoring and pain control. Serial chest x-rays were taken to evaluate the pneumothorax and resolution occurred without needing to place a chest tube. Pain control was with intravenous (IV) Tylenol and fentanyl and by mouth (PO) gabapentin and oxycodone. The patient was discharged home.

The health plan's determination is upheld in whole. 

The inpatient hospital admission is not medically necessary for this patient. The patient presented with trauma resulting in multiple contusions and a 5th rib fracture with a resulting small pneumothorax. The patient had healed prior rib fractures per the CT chest. Management of a small pneumothorax is conservative with repeat x-rays every 4-6 hours for the first 24 hours as the pneumothorax will resorb itself (Sharma et al 2008). There was not any documented evidence of concern for a tension pneumothorax. Given that the patient is young and has one fractured rib, thus surgical fixation is not required, and patient's pain was able to be controlled without a nerve block (May et al. 2016). Notably the patient's aspartate aminotransferase (AST) was 220 and alanine aminotransferase (ALT) 109, which is a pattern most consistent with alcohol use as AST is double the ALT and would be expected to decline (Salaspuro et al. 1987). An alcohol level is not available in the chart. As the patient was admitted to evaluate whether the pneumothorax would resorb and pain control and this would be expected to occur in less than 2 midnights without a complex management of care, thus patient does not meet criteria for the inpatient level of care (Centers for Medicare and Medicaid Services [CMS] guidelines). The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient ischemic attack (TIA)
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient was diagnosed with a transient ischemic attack (TIA). He has a history of coronary artery disease (CAD), hypertension (HTN), and diabetes mellites (DM). The patient was seen in the emergency department (ED) for left arm numbness for two hours. In the ED, the patient had no weakness or facial droop. There was no hemodynamic instability, focal neurologic signs, altered mental status or cardiac arrhythmias. The patient was admitted to telemetry. The request is for approval of the inpatient admission.

A computed tomography (CT) of the head showed no abnormality and an magnetic resonance imaging (MRI) of the brain showed no significant abnormality. A Computed Tomography Angiography (CTA) showed no large vessel occlusion.

The patient was without neurologic deficits, vitals were stable, and imaging showed no lesions. The patient could have been managed in a lower level of care, such as observation. The inpatient level of care was not medically necessary.

Per Coutts S. B. (2017), "The clinical definitions of TIA and ischemic stroke are based on focal neurologic signs or symptoms referable to known cerebral arterial distributions without direct measurement of blood flow or cerebral infarction. It is important to note that TIA and stroke represent different ends of an ischemic continuum from the physiologic perspective, but clinical management is similar. The historical time-based definition of TIA was based on full resolution of all symptoms within 24 hours of onset. The time-based definition has been debated in light of diffusion-weighted MRI demonstrating relevant ischemic lesions in 30% to 50% of patients fulfilling the time-based definition of TIA."

Per Kapral, M. K., et al., (2016), "Results: In our sample of 8,540 patients, the use of recommended interventions was highest in admitted patients, followed by discharged patients referred to prevention clinics, followed by those discharged without clinic referral. Eight percent of non-admitted patients returned to the hospital with recurrent stroke/TIA within 1 week of the index event. One-year stroke case-fatality was similar in admitted and discharged patients (adjusted hazard ratio 1.11; 95% confidence interval 0.921.34). Among patients discharged from EDs, referral to a stroke prevention clinic was associated with a markedly lower risk of mortality (adjusted hazard ratio 0.49; 95% confidence interval 0.380.64)."                                                 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Inpatient hospital admission 
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld.

This is a patient with a history of chronic obstructive pulmonary disease (COPD) who presented to the emergency department (ED) with complaints of dyspnea for 1 week. The patient also complained of increased wheezing and SOB (shortness of breath).

The patient had been admitted to the hospital for similar symptoms for Bronchitis/COPD and Rhinovirus infection. The patient was discharged home on oral (PO) prednisone.

At presentation to the ED, the patient was tachypneic and oxygen (O2) saturations were 92-93% (percent). The patient was treated with intravenous (IV) steroids, Magnesium, Duo Nebs, IV fluids and Azithromycin. The patient was admitted to the hospital with diagnosis of COPD Exacerbation.

As per history and physical, Temperature was 36.9 degrees C (Celsius), Respiratory Rate 14, Blood Pressure 126/78 millimeters of mercury (mm Hg), Heart Rate 82, and oxygen saturation 96% on room air. The patient was in no acute distress (NAD). 

White blood cell (WBC) count was 12.7K (thousand), Hb (hemoglobin) was 12.4, and the electrolytes were within normal limits (WNL).

Lactate was normal. Chest x-rays revealed no acute infiltrates. The patient was improved after treatment in the ED. The patient was on 2L (liters) oxygen via nasal cannula intermittently to keep oxygen saturation > (greater than) 96%.

The patient was continued on Robitussin, Symbicort, Duo Nebs and a steroid taper was initiated. The patient was also on oral Azithromycin and in no apparent distress. No use of accessory muscles was described, and some wheezes were heard. There were no signs of pneumonia (PNA) or acute infection and the patient was discharged.

The patient was stable to be discharged home on oral steroids, antibiotics, and oxygen after a period spent in observation status.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for the full hospital admission services is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal - Chronic low back pain. 
Treatment: Surgical Services. 
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The denial is upheld.

The patient is a male with a history of low back pain for more than 6 months. He had failed 6 months of conservative treatment. The provider documented "Modic changes in the lumbar (L)3 to sacral (S)1 vertebral bodies." The radiology report of magnetic resonance imaging (MRI) showed a hyperintense lesion (2.5 x 2.5 x 2.1 centimeter [cm]) in the L1 vertebral body, a stable lesion consistent with hemangioma in the L3 vertebral body, disc desiccation at L1-2 L3-4 and L5-S1, L3-4 level with grade 1 anterolisthesis, central and paracentral disc extrusion, and L3-4 facet arthrosis and a synovial cyst, and type 2 Modic changes of L3/4 endplate. This patient was recommended the Intracept procedure for his back pain. The issue is whether the Intracept procedure is likely to be more beneficial for this patient than any standard treatment.

The proposed health service or treatment Spinal procedure is unlikely to be beneficial for the patient's medical condition.
The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. The MRI find of Modic changes is one of indications and diagnostic criteria for vertebrogenic pain. The provider documented "Modic changes in the L3 to S1 vertebral bodies". However, the radiology report of MRI showed a hyperintense lesion (2.5 x 2.5 x 2.1 cm) in the L1 vertebral body, a stable lesion consistent with hemangioma in the L3 vertebral body, disc desiccation at L1-2 L3-4 and L5-S1, L3-4 level with grade 1 anterolisthesis, central and paracentral disc extrusion, and L3-4 facet arthrosis and a synovial cyst, and type 2 Modic changes of L3/4 endplate. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with radiographic evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies.1 In addition, hemangioma in the vertebral body is a relative contraindication for Intracept procedure. Therefore, this patient is not an appropriate candidate for the Intracept procedure based upon current clinical evidence.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal - Chronic low back pain. 
Treatment: Surgical Services. 
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The denial is upheld.

The patient is a male with complaints of low back pain. Magnetic resonance imaging (MRI) lumbar spine reported multilevel degenerative disc disease and multilevel degenerative changes. The patient sustained a low back injury. Currently, his pain is worse with prolonged sitting, but standing does help. As a result of his low back pain, he takes multiple medications. Physical exam of the lumbar spine demonstrated mild tenderness on palpation and percussion. There is a plan for Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral.

The proposed health service or treatment Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is not likely to be more beneficial than any standard treatment or treatments for the patient's disabling condition or disease. The patient has complaints of low back pain.
There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal - Chronic low back pain. 
Treatment: Surgical Services. 
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The denial is upheld.

The patient is a male diagnosed with low back pain. There is a letter of appeal from the provider stating that this procedure is an innovative procedure to address chronic low back pain identified by Modic changes and fulfills a treatment gap for patients with chronic back pain. It was noted that the patient has a history of low back pain and has had multiple treatments including facet injections, lumbar epidural steroid injections and medication management. Medications have included Motrin. Nothing has provided significant relief. The provider states the patient had a magnetic resonance imaging (MRI) showing Modic type II changes at disk space lumbar (L)3 - L4 and therefore his chronic back pain is coming from vertebrogenic changes at L3 and L4. The providers requesting reconsideration for approval. The patient was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance carrier as experimental and investigational. This determination is under appeal, which is the subject of this review.
There is no evidence that the proposed health service or treatment Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This treatment is not currently considered standard of care in the general medical community. There is a lack of high-grade evidence and large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure. There is no evidence to suggest this treatment would be more effective than that of standard treatment options.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Lumbar epidural steroid injection - Code 62323.
The insurer denied:  Lumbar epidural steroid injection - Code 62323.
The denial is upheld.

The patient is an adult male with chronic low back pain radiating down to the lower extremities. He previously had an epidural steroid injection with 60% relief. A second epidural steroid injection was requested at two levels, L (lumbar) 4-L5 and L5-S (sacral) 1. This was denied as two levels were requested via the interlaminar approach.

The proposed treatment is not medically necessary.

The patient is an adult male with chronic low back pain radiating down to the lower extremities. He previously had an epidural steroid injection with 60% relief. A second epidural steroid injection was requested at two levels, L4-L5 and L5-S1. This was denied as more than one level was requested. The requested procedure is not medically necessary as multilevel inter-laminar epidural steroid injections are not generally recommended and supported in the medical literature. The inter-laminar route is nonselective and therefore only one level should be performed in one setting. There is no literature evidence to support additional levels in the same setting are superior to a single injection.  Epidurogram studies have shown a single-level injection spreads to multiple levels and is non-specific. Therefore, multi-level interlaminar injections are redundant.  Given the above, the requested epidural steroid injection is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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


The patient presented to the emergency department with a history of progressively worsening abdominal pain. Evaluation included a physical exam, lab results, and a computed tomography (CT) scan. She was without a fever at the time of presentation and the heart rate was 89 beats/minute. Lab data identified a white blood cell count (WBC) count of 10.7 thousand (K). A CT scan yielded findings consistent with appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. The patient was admitted to the hospital and underwent a laparoscopic appendectomy. The clinical notes indicate an uncomplicated appendectomy with findings of appendicitis. She was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without a fever. The diet was advanced and pain management was converted to oral medications. She was discharged home.
At issue is the medical necessity of an inpatient stay.

An acute inpatient admission was not medically necessary.
This patient presented with abdominal pain. The evaluation with examination, lab data, and a CT scan supported the diagnosis of appendicitis. She was admitted to the hospital. The initial treatment included nothing by mouth (NPO) status, IV fluid, and an appendectomy. The early post-surgical course was uncomplicated and the patient was hemodynamically stable and tolerating a diet on the day of surgery. She was discharged from the hospital. A lower level of care would have provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring, if needed.
Generally accepted guidelines of care indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed with a lower level of care. 
The patient was clinically stable at the time of presentation and remained so during the course of care. 
The Milliman Care Guidelines (MCG) Inpatient and Surgical Care 25th Edition, Appendectomy, With Abscess or Peritonitis, by Laparoscopy state that the goal length of stay is ambulatory or 2 days postoperative. The criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed with an ambulatory level of care. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Reverse bite; crossbite.
Treatment: D8080 Braces, D8670 Monthly Visit and D8680 Retainer.

The insurer denied: D8080 Braces, D8670 Monthly Visit and D8680 Retainer.  The denial is overturned.

The patient is an adolescent female. The request is for orthodontic benefits. The patient has a Class III bite (i.e., reverse bite). The patient anterior teeth are in crossbite. The health plan denied coverage of the request due to the patient having a handicapping index score of 17. The denial is being appealed.

The requested D8080 Braces, D8670 Monthly Visit and D8680 Retainer are medically necessary.

The patient has several anterior teeth in crossbite with attachment loss. These are automatic qualifiers for benefits. The patient also states that due to her reverse bite, her teeth hurt her when she chews. This problem can also become problematic in the future due to potential TMJ (temporomandibular jaw) issues from the bite. The case has medical necessity for treatment and follow up visits. This patient's problem needs orthodontic treatment for correction.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Day Care Services - SDC Meals In Home For a Total of 3 Days Per Week
The insurer denied: Day Care Services - SDC Meals In Home For a Total of 3 Days Per Week
The denial is overturned

The patient is an elderly male with a history of dementia. He is alert and oriented, though he has forgetfulness and confusion due to dementia, total dependence with meal preparation, total dependence with ordinary house work, maximum assistance with managing medication, maximum assistance with bathing, personal hygiene, dressing upper and lower body, and walking, maximum assistance with toilet transfer. His activities of daily living status has declined. The patient needs assistance with activities of daily living due to heart failure, COPD (chronic obstructive pulmonary disease), and arthritis. In the recent Uniform Assessment System, the patient's condition has deteriorated compared to the previous evaluation. Currently, the patient is alert and oriented times one. The patient needs significant weight-bearing assistance. The patient is frequently incontinent of bladder and bowel daily. The request is for SDC (social day care) in-home meal services 3 days per week.

The requested health service is medically necessary.
The request for SDC (social day care) in home meal services is medically necessary. The patient needs help with dressing, walking, cleaning apartment, bathing and feeding, with several doctor appointments per week, the home care would not have enough time to prepare meals for the patient. The patient's activities of daily living status has declined, and the patient needs assistance with activities of daily living.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Adbry 150 MG/ML SC (subcutaneous) SOSY (solution pre-filled syringe)
The insurer denied Adbry 150 MG/ML SC SOSY.
The health plan's determination is overturned. 

The patient is a female with atopic dermatitis, treated with topical steroids, topical calcineurin inhibitors, Eucrisa, phototherapy and Dupixent. The Provider is requesting Adbry. 

Adbry is medically necessary for this patient.
This patient has tried and failed Dupixent. In the randomized controlled phase III trials, at week 16, more patients who received tralokinumab versus placebo achieved an IGA (immunoglobulin A) score of 0 or 1. Early improvements in pruritus, sleep interference, Dermatology Life Quality Index, SCORing Atopic Dermatitis (SCORAD) and Patient-Oriented Eczema Measure were observed from the first post-baseline measurements. The majority of week 16 tralokinumab responders maintained response at week 52 with continued tralokinumab treatment without any rescue medication (including topical corticosteroids). Therefore, Adbry is medically necessary in this case.