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

Diagnosis: Vomiting. 
Treatment: Inpatient Admission. 

The insurer denied: Inpatient Admission. 
The denial is upheld. 

The patient is an adult male. He was hospitalized for vomiting. 
He presented to the ED (emergency department) for evaluation of feeling lightheadedness and dizziness and thought he would pass out. This was followed by vomiting multiple times and accompanied by mild chest/abdominal tightness. His past medical history was significant for being treated for pharyngitis with an antibiotic just two weeks prior. The patient's vitals were stable: Blood pressure was 136/91, heart rate 93, and O2 (oxygen) saturation 97% on room air. EKG (electrocardiogram) showed sinus rhythm with ST segment elevation consistent with normal variant early diastolic repolarization versus pericarditis. Labs were remarkable for marginally elevated troponin. The patient's hospital course was notable for dry heaves and some diarrhea, as well. Treatment included IV (intravenous) fluids, normal echocardiogram, negative CT (computed tomography) abdomen, and overnight observation. He was discharged the following day. The requested coverage for inpatient hospitalization was denied coverage by the health plan as not medically necessary. The denial is being appealed. 

The Inpatient Admission was not medically necessary. 

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, positive troponin not explained by a systemic viral illness like in his case, pneumonia, acute abdomen/bowel obstruction, severe electrolyte abnormalities, sepsis, mental status changes, cardiac arrhythmia of immediate concern, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care that the patient received for probable acute viral gastroenteritis like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess skin and soft tissue
Treatment: Excision (15830), Excessive Skin and Subcutaneous Tissue (includes Lipectomy); Abdomen Infraumbilical Panniculectomy
The insurer denied: Excision (15830), Excessive Skin and 
Subcutaneous Tissue (includes Lipectomy); Abdomen Infraumbilical Panniculectomy
The denial is upheld.

This patient is an adult female who complains of a frequently infected panniculus and acute on chronic skin changes with keloids and bacterial infection due to massive weight loss. No bariatric surgery is reported. It is reported the patient had difficulty with walking, exercise and daily activities. Her weight fluctuates. Rashes and fungal infections below the overhanging panniculus has not responded to oral and topical antibiotics and antifungals. Photos show a female with a grade III pannus. The pannus is not elevated. Panniculectomy is planned.

The proposed treatment is not medically necessary.

The medical records do not provide documentation in the form of primary care physician (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. According to the American Society of Plastic Surgeons guidelines, "Patients considered for panniculectomy should document the type and duration of symptoms/treatment for panniculitis and photographs should confirm the patient's medical condition." Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. A dermatologist has not evaluated the rashes. The patient has not required hospitalization or treatment with intravenous or oral antifungal or antibiotic medications. The excess skin has not jeopardized health. Physician supervised treatment is the simplest and safest method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. 
In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al. the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2 percent. In addition, 41 percent had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscence. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and patient appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Ablation (code 64628)
The insurer denied: Intraosseous Basivertebral Ablation (code 64628)
The denial is upheld.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, and home exercises. The patient has failed OTC (over the counter) medications. MRI (magnetic resonance imaging) shows no Modic changes on the attached MRI (magnetic resonance imaging) report. Physical exam does not reveal any neurological injury.

The health plan should not cover the requested Intracept procedure.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, and home exercises. The patient has 
failed OTC (over the counter) medications. MRI (magnetic resonance imaging) shows no Modic changes on the attached MRI (magnetic resonance imaging) report. Physical exam does not reveal any neurological injury.
The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It has been shown effective in RCT (randomized controlled trials) with five-year results. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, while the provider describes Modic changes, this is not shown on the attached MRI (magnetic resonance imaging) report as read by the radiologist, which shows only mild spondylosis.
Additionally, the patient has not failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate. Lastly, the patient has only failed OTC (over the counter) medications, no attempt at pharmacological management has been made.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Ablation (code 64628)
The insurer denied: Intraosseous Basivertebral Ablation (code 64628)
The denial is upheld.

The patient is an adult male with axial low back pain radiating to the buttocks which began several years ago. His past treatments include chiropractor, medical branch block, and 
transforaminal epidural steroid injection at L5-S1 (lumbar five to sacral one). MRI (magnetic resonance imaging) of the lumbar spine from last year shows L5-S1 (lumbar five to sacral one) spondylosis with minimal disc bulging. The request for the Intracept procedure was denied coverage by the health plan as 
experimental/investigational. The denial is being appealed.

The health plan should not cover the proposed treatment.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.
At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such the health plan should not cover the proposed treatment.
The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease. Additional studies/trials are necessary to determine efficacy as compared to other conventional therapies. The requested health service or treatment has not been proven to be more beneficial than any standard treatment for the patient's condition or disease. Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e. NSAIDs [nonsteroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e. physical therapy, home exercise program, chiropractor (treatments), and interventions (i.e. epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Low back pain
Treatment: Pharmacy/Prescription Drugs/Pain Injections 64483 x 1, 64484 x 1
The health plan denied the requested Pain Injections 64483 x 1, 64484 x 1 as not medically necessary. The health plan's determination is upheld.

This patient is a male who presented with severe pain and low back radiating to the right leg. It is noted the pain got worse over a week ago. Over 3 months of physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), activity modifications and pain medications resulted in no relief. Activities of daily living s are greatly diminished. Physical exam at the sacral (S1) level tenderness reproduces pain, bending forwards is not possible, positive straight leg raise on the right at 35 (degree), knee jerk reflex decreased 1+, ankle jerk reflexes decreased 0. There is a plan for right (lumbar) L5 and S1 transforaminal epidural injection.
At issue is the medical necessity for the requested health service/treatment of Pain Injections 64483 x 1, 64484 x 1.

I uphold, in whole, the health plan's determination of medical necessity.

The health plan appropriately denied the injection, as there is no imaging provided to verify a herniated disc or spinal stenosis. The request is not medically necessary. Although the patient is noted to have radiating pain, there is no imaging provided to verify disc herniation or spinal stenosis causing the symptomatology. Furthermore, there is no indication of at least 6 weeks of activity modification have been trialed and failed. Overall, this request is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pre-Diabetes. 
Treatment: Ozempic (Semaglutide). 

The insurer denied coverage for Ozempic (Semaglutide). 

The denial is upheld. 

This is a patient diagnosed with Pre-diabetes and Obesity. This request is for Ozempic. As per letter, the patient has been on Ozempic. The patient also has polycystic ovarian syndrome (PCOS). The patient has lost 36 pounds and their comorbidities have also shown significant improvement. 

The patient's Hemoglobin A1C was 6.1%, 6.1%, and 5.5%. 

The patient's body mass index (BMI) was 44.22; weight was 274 pounds. On follow-up the patient's BMI was 40.35; weight was 250 pounds. 

The health plan acted reasonably with sound judgment as the patient does not have a  Food and Drug Administration (FDA)-approved diagnosis for the requested medication.

Semaglutide is a glucagon-like peptide-1 receptor (GLP1R) agonist1 that is FDA approved in the treatment of type II diabetes and obesity. (references 2-4) Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. (references 5-7) This medication is now available for the treatment of obesity in the form of Wegovy. There are no studies showing the safety or efficacy of the requested medication for patients who do not have diabetes such as this patient. There are no extenuating circumstances in this case. The request is, therefore, not medically necessary. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Ozempic (Semaglutide) is not considered medically necessary for this patient. 

Based on the above, the insurer's denial must be upheld. The medical necessity for Ozempic (Semaglutide) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and weakness post laparoscopic sleeve gastrectomy
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED)with complaints of dizziness and weakness. He was 2-days status post laparoscopic sleeve gastrectomy. Comorbid health conditions included hypertension, hyperlipidemia, and diabetes. He had been discharged home with a post-surgical diet and medication instructions. His vital signs at the time of presentation were normal. Examination revealed abdominal tenderness in the areas of the incisions, but no diffuse tenderness, guarding or rigidity. The white blood cell count (WBC) count was elevated at 21.5 thousand (K). His glucose was elevated at 247. The hemoglobin was 10.7 grams per deciliter (g/dl). The patient was admitted to the hospital.
He was transfused two units of packed red cells with resolution of the dizziness. The post-transfusion hemoglobin increased to 13 g/dl. The diet was advanced. The vital signs remained normal. He was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

No. Inpatient care was not medically necessary.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with a lower level of care during this time.
He presented with dizziness and weakness 2-days following a sleeve gastrectomy and 1-day following his discharge related to that procedure. His evaluation with examination and lab data identified post-surgical anemia with the hemoglobin of 10.7 g/dl. He was provided 2 units of packed red cells with resolution of his symptoms. He did not require acute surgical intervention. He was clinically stable during the period of monitoring and was able to be discharged with arrangements for outpatient follow up.
This patient's clinical needs could have been satisfied with a lower level of care. This lower level of care would have provided for clinical assessment and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible stroke

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient presented to the emergency department (ED) complaining of fatigue and dizziness along with weakness for approximately 5 hours.  On initial screening the patient had a right-sided facial droop and felt off balance while walking.  He noted decreased sensation to the left upper and left lower extremities.  He endorsed a history of smoking for 30 years consisting of 1/2 pack/day.  He denied changes in vision, hearing, denied falling, syncope, seizures, headache, a history of cerebrovascular accident or myocardial infarction, with no dyspnea, no abdominal pain, nausea, or emesis.  His physical examination noted cranial nerve deficit on neurological assessment.  He had right tongue deviation, right-sided facial droop that spares the forehead, although muscle strength was 5/5 in all extremities.  There was no extremity drift, but he did have decreased sensation to the left upper extremity.  He ambulated independently without ataxia and was negative for finger-to-nose testing.  The patient's blood pressure was 142/94 and he was not hypoxic.  A stroke alert was started and neurology at bedside ordered computed tomography (CT) scans, labs, and recommended admission.  CT scans were unremarkable with neurology requesting admission to neuroscience.  The patient's electrocardiogram (ECG) was normal, although laboratory values showed some abnormalities.  

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care for those individuals suffering from possible ischemic stroke include those who have a National Institute of Health Stroke Scale (NIHSS) score greater than 2, evidence of hemorrhagic transformation, altered mental status, dysphagia that warrants evaluation, significant arm or leg weakness, aphasia, gait impairment, findings on brain imaging that requires inpatient care, or but clinical stability is unclear.  It may also be indicated for those individuals who need inpatient care monitoring is indicated by thrombolysis performed or planned, or urgent inpatient procedures planned such as thrombectomy.  

The documentation provided for the review did not support that the patient satisfied these criteria.  When he presented to the emergency department, he had been experiencing symptoms after drinking half a pint of alcohol the day before and did not have any significant neurological abnormalities to justify inpatient stay.  The patient was hemodynamically stable and could have had his care safely and effectively rendered on an observational basis.  

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

Diagnosis: Nausea, Emesis and Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female who presented for nausea, emesis, and abdominal pain. The patient had frequent marijuana use. In the emergency department, her white blood cell (WBC) 
count was 12.6, potassium was 3.1, and hemoglobin was 11.6. Urine was positive for ketones and leukocyte esterase. The patient was treated with nothing by mouth (NPO), intravenous fluids, Protonix, intravenous Zofran, and serial abdominal exams. Her white blood cell count increased to 13. She had multiple episodes of vomiting and received intravenous Zofran for nausea control and intravenous morphine for pain control. 

The proposed treatment was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. The patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The patient did not have hemodynamic instability, 
severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for an extended period (e.g., more than 24 hours). The patient did not have an inability to maintain oral hydration (e.g., need for intravenous fluid support) that persisted; and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure needed that cannot be performed on ambulatory basis. Therefore, the proposed treatment was not medically necessary.