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

Diagnosis: Orthopedic/Musculoskeletal/Other/Spine Disorder.
Treatment: Pain Management/Pain Management Services/Ablation, 02 units.
The health plan denied the requested Pain Management Services/Ablation, 02 units as experimental/investigational. 
The health plan's determination is upheld.

The patient is diagnosed with a spine disorder. The provider states that the patient has a history of chronic back pain beginning over a year ago and has had multiple treatments including injections, medication management, radiofrequency ablation and transforaminal epidural steroid injection. Medications have included Cyclobenzaprine, Gabapentin, ibuprofen, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), and over-the-counter medications. Pain is impacting the patient's activities of daily living and self-care, and nothing has provided sustained relief. Pain is rated at 8/10. The provider states the patient had a magnetic resonance imaging (MRI) showing Modic type II changes at (lumbar) L3 - L4, L4 - L5, and L5 - (sacral) S1 and therefore this is the source of her pain. The provider states is procedure is founded on 30 years of basic science research linking Modic changes to chronic back pain. 
There is a progress note indicating the patient with complaints of back pain radiating from the low back into the bilateral posterior lateral thigh and calf including the lateral, bottom and dorsal aspect of the foot and left low back pain, unchanged since last visit and rated at 8/10. It was noted the patient had an epidural injection with pain improved by 80% lasting approximately six months, had radiofrequency ablation and bilaterally with 80% improvement and also had sacroiliac joint (SI) injection on the left with 80% improvement. On exam, there was paravertebral muscle spasm, tenderness and tight muscle band, tenderness at the bilateral posterior superior iliac spine, sacral sulcus bilaterally and left SI joint. There was limited range of motion. Motor strength was decreased at 4/5 at the first toe extensors on the right and left. Sensation was intact. There was positive facet loading bilaterally and positive pelvic rock test bilaterally. The patient was recommended to undergo another lumbar transforaminal epidural steroid injection and Intracept procedure.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

No, there is no evidence that the proposed health service or treatment Pain Management Services/Ablation, 02 units 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 (Intracept) is considered experimental and investigational in this patient who has benefited from alternative supported treatments. There is no evidence to suggest that this procedure is more likely to be beneficial than other standard treatments for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Other/Spine Disorder.
Treatment: Pain Management/Pain Management Services/Ablation, 02 units.
The health plan denied the requested Pain Management Services/Ablation, 02 units as experimental/investigational. 
The health plan's determination is upheld.

The patient is a female with a history of chronic low back pain secondary to degenerative disc disease. She has been treated with medications, epidural injections, and anti-inflammatories. A magnetic resonance imaging (MRI) of the lumbar spine revealed Modic changes in the disc spaces. Her treating physician the recommended Intracept procedure.

The health plan's determination regarding the proposed health service or treatment is upheld, in whole.

No. Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. While a recent study has shown promising results, the limitation of most of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Community Acquired Pneumonia.
Treatment:  Inpatient admission.

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

The patient is a male who presented to the emergency department (ED) with complaint of (C/O) bilateral (B/L) leg pain and a cough of 1 month duration. As per his history the patient also complained that sputum was occasionally blood tinged. The patient also complained of a 16 lb. (pounds) weight loss over 3 weeks. The patient denied history of (H/O) tuberculosis (TB). The patient was admitted to rule out (RO) TB. The patient was recently diagnosed (Dxed) with possible Hashimoto's Thyroiditis.

The patient's vital signs (V/S) at presentation to ED (emergency department) were: Temperature 98.2 F (Fahrenheit), Heart Rate 85, Respiratory Rate 20, Blood Pressure 117/82 mm Hg (millimeters of mercury). The patient was in no acute distress (NAD). Lungs were clear. Cardiovascular system (CVS) S (sinus rhythm)1 S2 were normal. The patient was alert and oriented (A X O X 3) with a non-focal neuro exam. Labs: white blood cell count (WBC) 10.6K (thousand), procalcitonin was low 0.06, Thyroid Stimulating Hormone (TSH) was elevated.

Chest x-rays revealed (CXR) B/L patchy ground glass opacity (GGO).

A computed tomography (CT) of the chest revealed subpleural reticular infiltrates and GGO. The patient was admitted to R/O TB. The patient had sputum samples sent to R/O TB.  The patient had a video-assisted thoracoscopic surgery (VATS) lung biopsy to R/O TB vs (versus) Vasculitis.

The patient was seen by Pulmonary, Rheumatology and Thoracic surgery. As per the attending, TB was unlikely based on the CT chest findings. This patient was treated with Unasyn and Azithromycin to treat community acquired pneumonia (CAP). TB was ruled out, and the biopsy was consistent with vasculitis.

The patient remained stable after admission. The patient's diagnosis (Dx) was vasculitis. This patient did not need acute inpatient hospitalization. He was afebrile and hemodynamically stable with Oxygen (O2) saturations 95% on Room Air. He was tolerating fluids and food. 

He could have given a sputum specimen as an outpatient. His weight loss was likely from some dosing of thyroid medications. The patient could have been placed in observation status while diagnostic studies and treatment was initiated.  This patient could have been discharged home once TB was ruled out with the VATS (Video-assisted thoracoscopic surgery) Lung Biopsy scheduled in an outpatient setting. The patient's thyroid medications could have also been adjusted in the outpatient setting.

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

Diagnosis:  Excessive overjet.
Treatment:  D8080 braces.

The insurer denied coverage for D8080 braces.   The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to excessive overjet. The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index as required asserting the patient exhibits the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirement on the HLD index, attaining a score of 17 points on review by internal reviewers. The patient's mother is appealing. 

Upon review of the submitted documentation it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying conditions is not met and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the findings of the insurer reviewer attaining a score of 17 points on the HLD index (8 overjet, 5 overbite, 4 labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown 
through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nonspecific abnormal finding of lung field
Treatment: CT (computed tomography) of Chest Without Contrast
The insurer denied: CT (computed tomography) of Chest Without Contrast
The denial is overturned.

The patient is an adult female with a 60-pack-year history of smoking. A baseline lung cancer screening chest CT (computed tomography) 2 years ago demonstrated calcified lung granulomas and two 2-mm (millimeter) and a 3-mm (millimeter) nodule in the right lower lobe and 3 mm ((millimeter) and 2 mm (millimeter) nodules in the left upper lobe for which a 12 month follow up CT (computed tomography) was recommended as a Lung-RADS (Lung Imaging Reporting and Data System) Category 2, benign findings. A chest CT (computed tomography) performed last year demonstrated calcified lung granulomas and stable 3-5 mm (millimeter) nodules in the right lower lobe and a stable 3 mm (millimeter) nodule in the left upper lobe for which a 12 month follow up CT (computed tomography) was recommended. The request is for coverage of last years' CT (computed tomography) chest.

The CT (computed tomography) of the chest without contrast (dye) was medically necessary.

The patient has a 60-pack-year history of smoking. A baseline lung cancer screening chest CT (computed tomography) of 2 years ago demonstrated calcified lung granulomas and two 2 mm (millimeter) and a 3 mm (millimeter) nodule in the right lower lobe and 3 mm (millimeter) and 2 mm (millimeter) nodules in the left upper lobe for which a 12 month follow up CT (computed tomography) was recommended as a Lung-RADS (Lung Imaging Reporting and Data System) Category 2, benign findings. As this patient already qualified for lung cancer screening, the recommended CT (computed tomography) chest imaging is at yearly intervals for Category 2 benign findings. The requested chest CT (computed tomography) of last year was medically necessary per USPSTF (United States Preventive Services Task Force) and CDC (Center for Disease Control and Prevention) national guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient has a history including tobacco abuse and past Gastric Bypass surgery.
She was seen at the primary provider's office where she reported poor appetite and significant weight loss. She had hypotension and hypoalbuminemia.

On presentation to the emergency room (ER), she was afebrile and hypotensive. She was placed on intravenous (IV) fluids and IV pressors due to persistent hypotension. She was noted as possible Sepsis. D-dimer was elevated. Computed tomography angiography (CTA) showed no pulmonary embolus but was noted to have a right lower lobe (RLL) opacity with some central clearing indicating a possible cavity.

White Blood Cell (WBC) count was 13.6, procalcitonin (PCT) was 0.24 and D Dimer 1.90. The patient tested positive for COVID-19 (2019 Novel Coronavirus).

Due to unclear etiology of hypotension and need for Neosynephrine IV and Midodrine to stabilize blood pressure, it was appropriate to admit the patient. She was also suspected to have tuberculosis (TB) due to hint of cavitation in the lung. Sepsis, cellulitis and pneumonia were also possible diagnoses. The patient was placed on broad spectrum IV antibiotics including Vancomycin and Zosyn. The patient continued to be hypotensive. The patient signed out against medical advice (AMA) despite the explained risks and appropriate inpatient admission.

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

The insurer's denial of coverage for the inpatient hospital admission overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is an adult male with past medical history of gastritis who presented to the emergency department (ED) with abdominal pain. He was afebrile with stable vital signs. Per the History and Physical documentation, he presented with one day history of severe, stabbing, abdominal pain which initially was suprapubic and radiated to the left testicle and was now more localized to the right lower quadrant (RLQ). He had an associated fever overnight. He denied nausea or vomiting or changes in bowel habits. On exam his abdomen was non distended with minimal tenderness in RLQ without rebound or guarding. There was no peritonitis. Labs revealed a white blood cell (WBC) count of 9.84. Computerized tomography (CT) of the abdomen revealed acute appendicitis with the distal appendix in the retrocecal location. The assessment was acute appendicitis, and the patient was admitted to surgery and placed on nothing by mouth (NPO) and given intravenous (IV) antibiotics and IV fluids

The patient was taken to the operating room and underwent an uneventful laparoscopic appendectomy with the findings of a swollen and inflamed retroverted appendix. The postoperative period was uneventful, the patient did well and was discharged on the day of surgery.

The patient had the operative procedure with no complications during or after the procedure that required acute inpatient care. A review of the records showed that the patient could have been placed in observation under monitoring, had an evaluation, had testing and been treated symptomatically while awaiting test results. There was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care. 

According to MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care 26th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; procedure completed; no evidence of post op or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet. 

Based upon the records provided, the patient reached these milestones, and could have been discharged following observation within a 23-hour observation period following surgery. Furthermore, according to MCG, the operative status criteria is ambulatory. 

This patient could have been observed rather than placed in an acute admission as he did have any indication for inpatient stay but rather observation. Non perforated appendicitis and lap appendectomy is an ambulatory procedure as the insurer noted.

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

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

Diagnosis: Paraoesophageal hernia
Treatment: Paraoesophageal hernia repair
The health plan denied the paraoesophageal hernia repair as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

This patient is a female with a body mass index (BMI) of 35 kilograms per meter squared (kg/m2)) with symptoms of gastroesophageal reflux disease (GERD) and Barrett's esophagus. She is treated with Omeprazole for this condition. She was diagnosed with a large paraoesophageal hiatal hernia. She has been evaluated for this condition with computed tomography (CT) scan of the chest that identified a large hiatal hernia. An esophagogastroduodenoscopy (EGD) showed a 6-centimeter (cm) hiatal hernia. Prior upper endoscopy showed the large hiatal hernia and CT scan also identified the paraesophageal hernia.

Records support the medical necessity of the proposed paraesophageal hernia repair for this patient.
The submitted medical records support that this patient has symptoms of GERD and has the diagnosis of Barrett's esophagus related to a 6-cm paraesophageal hernia. She has been appropriately evaluated with endoscopy and CT scan imaging. These studies confirm that there is a 6-cm hiatal hernia with the fundus of the stomach within the mediastinum. There is confirmed pathologic esophageal acid exposure based on the diagnosis of Barrett's esophagus. CT scan has also confirmed the findings of a large hiatal hernia. This patient has been treated with anti-acid medications with refractory symptoms. Proton pump inhibitor (PPI) therapy will minimize the acidity of the refluxed material but will not prevent ongoing reflux and regurgitation.
The proposed laparoscopic repair of the large hiatal hernia is medically necessary for this patient per the included guidelines and nationally accepted guidelines for patient selection. The included guideline states that paraesophageal hernia repair is medically necessary for symptomatic individuals with a paraesophageal hernia demonstrated on imaging or endoscopy and one of the listed conditions. In this case the patient has a large retrocardiac paraesophageal hernia seen on CT and EGD and has gastroesophageal reflux symptoms that persist despite PPI treatment. She also carries the diagnosis of Barrett's esophagus.
There is no alternative, nonsurgical therapy that has been shown to result in clinical improvement with regard to GERD symptomatology as surgical repair as proposed.
Per Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines (cited below):
All symptomatic paraesophageal hiatal hernias should be repaired, particularly those with acute obstructive symptoms or which have undergone volvulus. In this case the documented hiatal hernia is symptomatic (aspiration, GERD).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda
The insurer denied Saxenda. 
The health plan's determination is overturned. 

The patient is a female with a history of obesity body mass index (BMI) of 37-37.9. The request is for coverage of Saxenda 3 milligrams (mg) Pen Injector. 

Saxenda 3 mg Pen Injector medically is necessary for this patient.
Lifestyle changes remain the first line of therapy according to the American Heart Association (AHA) / American College of Cardiology (ACC) 2013 obesity guidelines, which for obese and overweight individuals, recommends a comprehensive lifestyle program including lower calorie diet and increased physical activity (strong recommendation with a strong level of evidence, and which benefits significantly outweigh risks). The 2015 Endocrine society obesity guidelines and the 2016 American Association of Clinical Endocrinologists (AACE) obesity guidelines recommend consideration of weight loss medication in patients with BMI>27 with comorbidity or BMI over 30, but only as adjuncts to reduction of food intake and increased physical activity.
In patients who have tried and had an inadequate response to lifestyle modification, consideration of obesity medication such as Saxenda is appropriate - this is in congruence with the 2016 AACE and 2015 Endocrine society and general standard of care obesity guidelines.
This patient was previously enrolled in a comprehensive lifestyle modification program and had to take a temporary hiatus due to surgery and recovery. Her BMI is >30. She would benefit from Saxenda. It is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inflammatory Bowel Disease
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male. He presented to the ER (emergency room) with LLQ (lower left quadrant) pain, nausea and vomiting x (times) 1 and diarrhea x 1.

The patient was hemodynamically stable, with a normal WBC (white blood count). His CT (computed tomography) was with colitis. He was hydrated and started on IV (intravenous) antibiotics.

The next day the patient's symptoms had improved, and his diet was advanced. He was discharged on oral antibiotics for outpatient colonoscopy.

The Inpatient Hospital Admission was not medically necessary.

The patient presented with acute abdominal pain and nausea, with an episode of diarrhea and vomiting. He was hemodynamically stable. WBC (white blood count) was normal, and CT (computed tomography) revealed pancolitis. He was started on antibiotics, and his symptoms had improved, and he was discharged for outpatient colonoscopy. As he was hemodynamically stable without multiple bloody bowel movements, and no evidence of systemic illness without tachycardia, fever, anemia or evidence of bleeding, obstruction or intractable pain, acute inpatient admission was not medically necessary. The patient could have been treated at a lower level of care.