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


Diagnosis: Low back pain

Treatment: intraosseous ablation of basivertebral nerve via Intracept Procedure

The insurer denied coverage for intraosseous ablation of basivertebral nerve via Intracept Procedure

The denial is upheld 

This patient has chronic low back pain. She takes non-steroidal anti-inflammatory drugs (NSAIDs) and Tylenol for pain. She is post multi-level laminectomies, facetectomies and foraminotomies. She has had chiropractic therapy as well as physical therapy. She has had epidural steroid injections as well as a spinal cord stimulator trial. On her magnetic resonance imaging (MRI), Modic changes Type I and II were identified at lumbar (L)3-L4, L4-L5 and the request is for radiofrequency (RF) ablation of the Basivertebral nerves (BVN) at L3, L4 and L5.	

The publications to date have been company sponsored and have methodology flaws. There is no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

In summary, the denial for the intraosseous ablation of basivertebral nerve via Intracept Procedure and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Emboli.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is an elderly female who presented with left sided chest pain and dyspnea. She had a history of diabetes, hypertension, and heart failure (heart failure with reduced ejection fraction [HFrEF]). One day before, the patient had an eight-hour plane ride. Exam showed asymmetric swelling of lower extremities. She was hypertensive and pulse was 97. The patient's D-dimer and brain natriuretic peptide (BNP) were elevated. Pulmonary emboli were suspected due to history and findings. Computed tomography angiogram (CTA) of the chest was performed and was diagnostic of multiple pulmonary emboli. 
The patient was treated for exacerbation of her congestive heart failure (CHF) with diuresis, and heparin for her pulmonary emboli. The patient had episodes of bradycardia and low blood pressure. Acute renal failure was considered. Echocardiogram revealed left ventricular (LV) function had decreased. The patient had multiple work ups including cardiac and oncology. She was hospitalized for 4 days. The inpatient hospitalization was denied and is being appealed.

The proposed treatment was medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. In this case, the symptoms were typical and consistent with findings of significant pulmonary embolism and progressive congestive heart failure (CHF). The patient's exam and cardiac 
findings were normal. Her echocardiogram showed marked wall motion abnormality. The physicians' treatment did reflect serious concern about patient's cardiac and pulmonary conditions. 
The letter of appeal was carefully considered, and it did give evidence to support inpatient level of care. There were several examples of care requiring inpatient level of care such as assessment of fluid status several times per day - this needed to be closely watched with combination of heart failure with reduced ejection fraction (HFrEF) and renal insufficiency in the setting of 
hemodynamic significant pulmonary embolism: to fully anti-coagulated a patient, heparin delivery and adjustment are best in the inpatient setting; and daily labs including renal function 
and hemoglobin with potential need to adjust immediately. The patient had episodes of bradycardia and hypotension which required immediate evaluation. The patient needed to be bridged to an oral anticoagulant before heparin could be discontinued. She also had comorbidities of hypertension, diabetes, congestive heart failure (CHF) and age. There were several etiologies for hypotension with pulmonary embolism and congestive heart failure (CHF) both being present. Inpatient level of care was medically necessary. The denial explanation was not consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Loose crown.

Treatment: D2954/prefab (prefabricated) post/core and D2750/porc (porcelain) /gld (gold) crown on tooth #5.

The insurer denied coverage for D2954/prefab post/core and D2750/porc/gld crown on tooth #5.

The denial is upheld.
 

Upon review of the submitted documentation which includes copies of one bitewing radiograph with crown in place, one periapical radiograph without crown, narrative letter from the patient, narrative letter from the dentist and insurer correspondence, it appears that this patient presented to the dentist for evaluation of a longstanding crown on tooth #5. Based on the stated clinical findings, this crown was placed over 10 years prior and had come loose and was recemented several times. At this point the dentist is recommending post and core and subsequent replacement full coverage crown restoration for tooth #5. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support it. 

Based on the submitted information for review, particularly the radiographic examination/periapical radiograph #5 exhibits significant loss of coronal structure down to the gingival margin, compromising tooth integrity and tooth structure and involving the root structure. Effectively, at this point this tooth is a retained root tip. The extent of coronal loss renders this tooth a poor support for full coverage restoration. Additional definitive treatment in the attempt to maintain this tooth in the arch would require endodontic therapy, and periodontal crown lengthening surgery, which would further compromise crown and root ratios, leaving less tooth structure than currently exists as support of a fixed crown. As this tooth would be prosthetically poor support for a crown restoration, with or without post and core, it is determined that the services as recommended are not medically necessary. 

Uphold denial for D2954/prefab post/core and D2750/porc/gld crown on toot #5 as not medically necessary as this tooth exhibits significant coronal destruction and therefore has a poor long-term prognosis and would be unsuited prosthetically for support of a full coverage crown.

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

D2954/prefab post/core and D2750/porc/gld crown on tooth #5 is not considered medically necessary for this patient.

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 D2954/prefab post/core and D2750/porc/gld crown on tooth #5 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurring Hernia.
Treatment: Hospital Admission.
The insurer denied: Hospital Admission.
The denial is upheld.

The patient is an adult female. She presented to the hospital with nausea, vomiting and abdominal pain. The patient was treated for recurrent ventral hernia. The patient's hospital admission is under review.

The proposed inpatient hospital admission was not medically necessary.

The patient is an adult female. The patient's hospital admission 
was denied by the health plan stating that: "This procedure is usually done in one day (ambulatory procedure). Sometimes you may need to stay overnight or up to 48 hours for observation and additional treatment. We have no notes that you needed to be watched in the hospital (for longer than observation level of care [48 hours]). We have no notes you had problems during or after the procedure that needed you to stay in the hospital for longer than 48 hours."

Review of the submitted medical records reveals that all of the medical care that was provided to this patient including intravenous fluids, diagnostic studies/tests, and intravenous and oral medications including pain medicine and antibiotics could have been provided in a lower level of care. Monitoring of oxygen saturation and vital signs monitoring all could have safely, effectively, and efficiently been provided as Observation Care without requiring a full inpatient admission. This is consistent with the health plan's denial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pulmonary embolism.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient was sent to the emergency department (ED) by his primary doctor for a high platelet count. The platelet count was in the 900s. The patient reported some intermittent chest pain for the past four weeks. Vital signs in the ED were normal, oxygen saturation was 99 percent (%) on room air. Lungs were clear, and the cardiac exam was unremarkable. There was no labored breathing, and he was speaking in full sentences. The neuro exam was non-focal and the patient was alert and oriented x 3.

The white blood cell count (WBC) was 11,400, hemoglobin 16.3, platelets 944,000 and the electrolytes were within normal limits. A Chest X-ray showed no acute pathology, and the electrocardiogram was normal sinus rhythm with no acute ST-T wave (intervals on a ECG) changes. A computed tomography angiogram (CTA) revealed a right lower lobe pulmonary emboli and focal opacity in the right lower lobe consistent with a pulmonary infarction. The echocardiogram was unremarkable, and there was no right heart strain. A deep vein thrombosis study was negative.

The patient was started on Lovenox and was seen by Hematology who recommended a bone marrow biopsy. The patient had a bone marrow biopsy and was subsequently switched to oral (PO) Eliquis and discharged home.

This patient did not need hospitalization for treatment of a pulmonary embolism (PE). He could have been in observation initially. Observation could be for up to 48 hours. Once he remained stable, he could have been switched to PO (oral) Eliquis and discharged home. The patient was placed on PO Hydroxyurea for his thrombocytosis.

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

Diagnosis: Pancreatic head mass and biliary ductal dilatation/obstruction.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult female who presented to the hospital with complaint of dark urine, nausea/vomiting, and weakness over the past ten-days. She had a medical history of hypothyroidism. At the time of presentation to the emergency department, the patient had normal vital signs. A complete blood count (CBC) and serum electrolytes were normal. A complete metabolic panel identified elevated transaminases and bilirubin. The patient's evaluation included imaging with ultrasound, computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) that identified a pancreatic head mass and biliary ductal dilatation/obstruction. The patient was admitted.
Gastroenterology and Oncology consultations were obtained. On the second day, the patient was clinically stable with normal vital signs. The plan was for transfer to another hospital. On the third day, the patient was transferred to the other hospital for further evaluation and treatment of the pancreatic head mass and obstructive jaundice. 
The health plan's rationale for denial of inpatient level of care, per the denial letter is that there was no clinical issue that mandated inpatient care. Per this letter, the Health Plan rules say that observation is medically needed for short term monitoring of a problem while getting a treatment plan.

The inpatient stay was not medically necessary.

Based on the submitted clinical documentation, an inpatient level of care was not medically necessary in this case. This patient was admitted to the hospital with the condition of obstructive jaundice secondary to a pancreatic mass. Vital signs were normal at the time of presentation. The patient underwent diagnostic evaluation that included lab data, ultrasound, computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP). The patient remained clinically stable during this time and the treatment plan was for transfer to another hospital for further evaluation and 
treatment. The patient remained clinically and hemodynamically stable during this period of monitoring. The submitted medical records support that this patient's care and evaluation could have reasonably been performed with an observational level of care with subsequent transfer to a higher level of care. Inpatient level of care was not medically necessary. An observational level of care would have permitted for the initial assessment, diagnostic evaluation with labs and imaging and arrangements for transfer for definitive care and treatment. The patient was clinically stable at the time of presentation and remained so during the period of monitoring as supported by the corresponding medical records and progress notes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male. He was admitted for worsening shortness of breath, dizziness and generalized weakness. He endorsed decreased grip strength, ambulatory capacity and frequent twitching. CT (computed tomography) scan of the patient's head was unremarkable. Chest x-ray was done and was also unremarkable. Cardiac enzymes were done and were unremarkable. Neurology was consulted. MRI/MRA (magnetic resonance imaging/magnetic resonance angiography) of the head and neck were done, as well as ultrasound of the carotid artery. 
The inpatient hospitalization was denied coverage by the health plan, as it was determined to not meet criteria for inpatient admission. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

According to MCG (Milliman Care Guidelines) guidelines 25th edition for neurology, inpatient admission is warranted when there is a severe neurologic deficit as well as changes seen on MRI (magnetic resonance imaging). This was not the case with this patient. The workup could have been done on an observation or outpatient basis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is an adult male. He presented to the emergency room for evaluation of severe and progressive dizziness with upper extremity paresthesia. There was also nausea and vomiting, as well as loss of balance. Labs as well as imaging were ordered. During the neurological examination, the patient had an episode where he lost balance and nearly fell. He was admitted to the telemetry unit for the management of pre-syncope. It was felt that the pre-syncope was severe and progressive, and he was evaluated for neuro-cardiogenic versus neurosyphilis etiology.

The admission was denied coverage by the health plan, as it was determined to not meet medical necessity for level of care. The denial is being appealed.

The Inpatient Hospital Admission was medically necessary.

Inpatient admission was medically necessary for this patient. According to MCG (Milliman Care Guidelines) guidelines, admission to telemetry unit is indicated when there is unexplained syncope or other neurologic event suspected of being due to arrhythmia due to increased risk. This was the patient's presentation, and it was severe in nature. Furthermore, due to the nature of continuous telemetry, evaluation could not have been done in an outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment:  braces and monthly visits .

The insurer denied coverage for braces and monthly visits .

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, 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 requirements on the HLD index attaining only 7 points on review by internal reviewers. The orthodontist is appealing on behalf of the patient. 

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 
cross bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore 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.

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 insurer's denial of coverage for braces and monthly visits. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female. She presented with abdominal pain and low-grade fever. She was evaluated in the emergency department with a CT (computed tomography) scan that showed a possible colovaginal fistula, as well as colitis and UTI (urinary tract infection). She was admitted for IV (intravenous) antibiotics and evaluation by general surgery. She was subsequently discharged without intervention.

The Inpatient Hospital Admission was not medically necessary. 

The patient presented with a symptomatic colitis and urinary tract infection. While she was treated appropriately with antibiotics, and this led to improvement in her symptoms, the health plan's 
decision is appropriate. The treatment could have been accomplished at a lower level of care. In review of the records, inpatient treatment was not required in this case. The patient was not septic and did not require intense monitoring. She was treated with antibiotics and discharged home in a reasonable fashion. This is appropriate for a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied inpatient admission
The insurer's denial was upheld

The patient presented to the emergency room (ER) with complaints of abdominal pain and diarrhea. The patient was admitted with similar symptoms. Imaging revealed diffuse dilatation of small bowel loops with questionable transition points. There was concern for a bowel obstruction. The patient was admitted for care. The patient was kept on nothing by mouth (NPO). The patient was given intravenous (IV) fluids and IV Zosyn. The patient's condition improved. 

The patient had an appendectomy and then presented with abdominal pain and diarrhea. He was previously discharged with a foley catheter, but it had now been removed. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The computed axial tomography (CAT) scan showed dilatation of the small intestine with a questionable transition point. There was fluid in the pelvis, but no abscess was present. Intravenous (IV) fluids and antibiotics were given. It was felt that he had a possible infected hematoma. By the next day, he was able to be advanced to a regular diet. His symptoms improved. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

This patient had recent surgery and now had a possible ileus. He required IV hydration and antibiotics. He responded quickly and his diet was able to be advanced. This treatment could have been given with observation status. He did not have peritoneal signs, was able to tolerate a diet after observation, and did not require any further surgical interventions. He did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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.