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

Diagnosis: Right Foot Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the hospital after suffering a fall. She had undergone a hallux valgus correction several days prior. Her past medical history was significant for hallux valgus, Hashimoto's thyroiditis, hypothyroidism, ileus, Clostridium difficile, Covid, gastritis, breast augmentation, lymph node biopsy, Lasix surgery, labial fusion and anxiety. She takes famotidine, levothyroxine, oxycodone and Senna. She was unable to tolerate crutches due to her breast surgery and was deemed unable to perform the activities of daily living.

When the patient presented to the hospital, an x-ray was done, which showed osteotomy in proper alignment with subcutaneous air, vascular calcifications and soft tissue swelling noted. Physical therapy was instituted, and orthopedic surgery was consulted. She was found by a physical therapist in the orthopedics department to have impaired balance. She was found to have decreased ability to use her legs for bridging and pushing with range of motion. She remained non-weight-bearing. Due to her pain she was continued on oxycodone. Social work was consulted, and she was deemed not safe to go home because of her living environment and the requirement to use a scooter, which did not fit in her home. She was then discharged to a subacute facility. She was cleared for discharge the following day.

No, the Inpatient admission was not medically necessary.
The patient was admitted several days after hallux valgus correction.  Typically this sort of operation does not require inpatient admission.  The patient then was discharged to rehab.  This could have been performed with a lower level of service.  There was no documented medical condition other than difficulty utilizing her knee scooter and maintaining her non-weight-bearing status presented.  Social work consultation and rehab placement, which she ultimately received and required, can be obtained without inpatient admission, and therefore inpatient admission was not medically necessary (1).

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The inpatient stay was not medically necessary, therefore the health plan did reasonably (Please see above for rationale).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment:  Formulary exception for Ubrelvy
The insurer denied  Formulary exception for Ubrelvy.
The denial is upheld.

The patient is a male with migraine headache disorder. The provider indicated that the patient could not take triptans due to hypotension and aortic insufficiency. The provider is requesting Ubrelvy. The requested medication was denied coverage, as the patient has not tried and failed the appropriate preferred medications for his condition.

No, the health plan should not cover the Formulary exception for Ubrelvy.
There is no documented reason the patient cannot be treated with the preferred formulary agents. Hypotension and aortic insufficiency are not contraindications to the use of triptan medications. Triptans are FDA (United States Food and Drug Administration)-approved for the acute treatment of migraine headaches and are considered first-line, standard-of-care, abortive agents (Thorlund et al.). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis.
Treatment:  Consumer Directed Personal Assistance.

The insurer denied Consumer Directed Personal Assistance. The health plan's determination is overturned.

The patient is a male with past medical history of osteoarthritis, dysthymic disorder, schizophrenia, gastroesophageal reflux disease (GERD), obesity, dizziness, chronic pain, insomnia, and allergic rhinitis. The provider noted that the patient's condition was stable and he was following up with psychiatry and would benefit from light housekeeping and his sister provides daily informal support. The patient had telephonic assessment performed that assessed the patient at maximum assistance with tasks of meal preparation and ordinary housework while extensive assistance with task of shopping. The patient was assessed at limited assistance with tasks of managing finances, managing medication, stairs, transportation, equipment management, bathing, personal hygiene, and dressing upper/lower body and set up help with phone use. With tasks of walking, locomotion, transfer toilet, toilet use, bed mobility and eating, the patient was assessed as independent. Notes from the telephonic assessment stated the patient cannot cook meals because he gets very nervous when he cuts the food (had history of cutting himself in the past when chopping food), required assistance with housework, shopping, meal preparation, and laundry. In addition, the patient stated he has difficulty bending down to reach his feet due to pain in the knees and decreased range of motion in the lower back and needs assistance with showering and lower body dressing.

Consumer Directed Personal Assistance is medically necessary for this patient. The patient has osteoarthritis, chronic pain and schizophrenia with assistance needs with multiple tasks as outlined in the assessment tool. The patient had assistance needs with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, equipment management, bathing, personal hygiene, and dressing upper/lower body. The Consumer Directed Personal Assistance services are not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL) tasks. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested Consumer Directed Personal Assistance services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This full-term female infant presented with difficulty in breathing, pallor for one day in the setting of 7 day history of congestion and rhinorrhea. A sibling was at home with respiratory syncytial virus (RSV). There was a decrease in oral (PO) intake from baseline and urine output. Prior to presenting in the emergency department (ED), she was seen by her primary medical doctor (MD) and prescribed azithromycin and Decadron. Her physical examination after initial ED interventions was documented as having minimal subcostal retractions, no flaring and no distress. Although initially the oxygen saturation was 97% (percent) on room air, the ED attending documented "hypoxic to 88% while asleep, placed on 1 [liter] L nasal cannula." Diagnostic studies included a chest x-ray (negative), partial sepsis work-up, complete blood count (CBC), urinalysis, and general chemistries. Treatment included oxygen (as above), an IV (intravenous) Normal Saline bolus, and then, D [dextrose] 5 Normal Saline at maintenance. She was diagnosed with bronchiolitis and admitted due to hypoxia in the setting of RSV. 

Following admission, the patient was gradually weaned to room air. Her respiratory status "remained well with no increased work of breathing or desaturations." She maintained good PO and urine output. She was discharged home.

According to Milliman Care Guidelines (MCG): Bronchiolitis, P-80, admission is indicated for Hypoxemia [as indicated by patient without baseline need for supplemental oxygen who now requires supplemental oxygen to keep SaO2 (oxygen saturation) greater than 90% or PO2 (partial pressure of oxygen) greater than 60 mm Hg (millimeters of mercury)]. 

According to MCG: Bronchiolitis: Observation Care (OC-044), observation care is indicated for 1 or more of the following:

1) Infants with abnormal respiration, as indicated by 1 or more of the following:
	
a) Tachypnea b) Retractions c) Wheezing

2) Ability to feed or maintain hydration unclear (i.e. [that is], need more time to observe and monitor to determine if there is an issue).

In view of the above, this patient's care met MCG:P-80 for inpatient status because there was hypoxia, i.e., oxygen saturation of 88% while asleep.

The insurer's denial of this admission is overturned.

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

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

Diagnosis: Low Back Pain
Treatment: Intracept Procedure (22899 & C9752)
The insurer denied the Intracept Procedure (22899 & C9752).
The denial is upheld.

The patient is a male with a history of chronic low back pain who has failed ESIs (epidural steroid injections), facet injections, and medications. His physical exam is positive for only tenderness to the low back. The Intracept procedure has been recommended. The procedure was initially denied, as the patient's insurance policy finds the procedure to be experimental. This decision has been appealed.

No, the health plan should not cover the Intracept procedure.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new FDA (United States Food and Drug Administration)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. 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. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact, most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion. Spinal cord stimulation is also an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose.

However, despite the above, this patient has not failed or attempted sacro-iliac joint interventions, which is a common cause of axial low back pain. The patient's pain is axial; there is notation of facet arthropathy on the MRI (magnetic resonance imaging). Modic changes can be present in no vertebrogenic back pain. No physical exam is included in the submitted notes.

Therefore, while the Intracept procedure is an FDA-approved procedure that is not experimental/investigational, and is a reasonable option, it should be employed after all conventional and evidence-proven alternatives have failed. SI (sacroiliac) joint interventions have been shown to be effective in low back pain. Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial than any standard treatment. Standard treatments have been shown to be effective.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure (22899 & C9752)
The insurer denied the Intracept Procedure (22899 & C9752).
The denial is upheld.

The patient is a male. He has history of chronic lower back pain related to a motor vehicle accident. His pain score is 5-6/10, and his pain worsens with sitting. He takes Motrin and occasional muscle relaxant. His radiculopathy improved after the lumbar facet injections. This is a request for Intracept procedure at L3,4 (third lumbar spine vertebra, fourth lumbar spine vertebra).

MRI (magnetic resonance imaging) Lumbar spine revealed Modic II changes at L3 (third lumbar spine vertebra) and L4 (fourth lumbar spine vertebra), multilevel central spinal stenosis, degenerative disc disease, facet arthropathy.

No, the health plan should not cover the Intracept procedure.

The requested Intracept procedure is experimental/investigational.

No, the Intracept procedure cannot be concluded to be more beneficial.

It is unproven and not medically appropriate, due to insufficient evidence of efficacy. All studies performed to date have been industry sponsored. Future non-industry-funded trials will be needed to confirm these results.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Disorder. 
Treatment: Orthotics. 

The insurer denied: Custom shoe inserts. 
The denial is upheld. 

The patient is a male who presented to the podiatrist's office for evaluation of his heel for about 1 month. He states the pain was an insidious onset, mild to moderate in severity, with pain in the morning. The patient has had a history of (h/o) foot pain about 3 years ago where he was diagnosed with pes planus deformity. He had been given conservative care and set up for custom molded orthotics. His custom molded orthotics are now worn down. The patient had pain on palpation of the medial tubercle with no evidence of edema. He was diagnosed with plantar fasciitis which is a new diagnosis per the medical records. He was recommended new custom orthotics, shoe gear modifications, injections and stretching exercises. The issue is the medical necessity of the custom molded orthotics. 

The requested treatment of custom shoe inserts are not considered medically necessary. The patient has history of foot pain back and diagnosed with pes planus bilaterally. He was given conservative treatment and custom molded orthotics which helped alleviate the foot pain. The patient then presented to the podiatrist's office 3 years later  complaining of 1 month of heel pain. He had not been given any conservative measures before being recommended new custom molded orthotics. 
Custom molded orthotics are not to be used as first line treatment. Based on the standard of care, the patient should be given options of first line treatment such as physical therapy, strapping, stretching, change in shoe gear, injections, anti-inflammatory meds, etc. before custom molded orthotics are tried. 
Thus, the custom molded orthotics are not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This male patient has a history of alcoholism and presented for detoxification.  Vital signs were as follows: pulse 94, respiratory rate 18, blood pressure 143/77, and oxygen saturation 97% on room air.  His exam was remarkable for slightly distended abdomen.  The patient's labs revealed the following: sodium (Na) 142, potassium (K) 4.4, carbon dioxide (CO2) 21, blood urea nitrogen (BUN) / creatinine (Cr) 4/0.6, aspartate aminotransferase (AST) 105, alanine aminotransferase (ALT) 81, white blood cell (WBC) 4.37, hemoglobin / hematocrit (H/H) 12.7/34.5 and platelets 195.  His urine toxicology was positive for cannabinoids; alcohol (ETOH) was 259.  The patient's electrocardiogram (EKG) showed normal sinus rhythm (NSR). 

The patient was admitted for alcohol intoxication.  Plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. The patient's vital signs were stable. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was four.  He was continued on the  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol and plan to trend liver function tests (LFTs). The patient's vital signs were stable.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was two.  He was to follow up with case management for outpatient rehabilitation.  The patient was cleared for discharge. 

No, the proposed inpatient admission was not medically necessary. 

This patient was admitted after presenting with alcohol intoxication.  The patient was hemodynamically stable and afebrile.  He did not have tachycardia.  He did not have vomiting, delirium, seizures, or gross tremor.  Labs were remarkable for mild transaminitis and elevated alcohol level.  He did not have findings of alcohol withdrawal.  The patient was admitted with plan for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  He remained clinically stable during the hospital stay without signs of severe alcohol withdrawal.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores were low.  The patient did not have symptoms that required an acute inpatient level of care.  He had not failed management at a lesser level of care. 

Medically necessary services are those which are:- safe - effective- generally accepted national standard of medical practice - not provided primarily for convenience of the patient or the practitioner - the least intensive and/or most appropriate alternatives among diagnostic and treatment option. The requested Inpatient Hospital Admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.  Withholding the treatment would not reasonably be expected to affect the patient's health adversely. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Infection (bronchiolitis). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male. The service under review is Inpatient Hospital Admission for the diagnosis of bronchiolitis.  This service was denied as not medically necessary and this decision is being appealed.

The patient has a past medical history of spina bifida repair, VP (Ventriculo-Peritoneal) shunt, neurogenic bladder, and paralyzed legs. He presented to ER (emergency room) with fever, cough, congestion, heavy breathing. 

On exam the patient's HR (heart rate) was 130, RR (respiration rate) 40-42, SpO2 (pulse oximetry) 89-90%, use of accessory respiratory muscles/retractions.  He was positive for infection with RSV (respiratory syncytial virus).  His chest x-ray was without focal infiltrates. 

The patient was treated with albuterol and Decadron but did not improve.  He was given 2 to 3 LPM (liters per minute) O2 (oxygen) via NC (nasal cannula) and intravenous fluids (for decreased oral intake).  The following night he still needed 1 LPM (liter per minute) O2 (oxygen).  On day of discharge he continued to have mild retractions and was able to maintain SpO2 (pulse oximetry) > [greater than] 90% for approximately 5 hours without supplemental oxygen. 

Yes, the Inpatient admission was medically necessary. 

Given the information provided concerning the patient, the attending physician's recommendations are in line with generally accepted practice guidelines such as MCG (Milliman care guidelines) guidelines for Bronchiolitis #ORG: P-80 (ISC).  The patient had Hypoxemia (eg, oxygen saturation less than 92% on room air), Feeding difficulties, Heart rate less than or equal to 130 beats per minute in infant 6 to 11 months of age, and tachypnea with respiratory rate greater than 40 breaths per minute in infant 6 to 11 months of age.  The patient remained in the hospital for 2 nights, and was discharged within approximately 5 hours of being able to maintain SpO2 (pulse oximetry) > [greater than] 90% without supplemental oxygen. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

Since the hospitalization was medically necessary, by denying this service the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Overactive Bladder
Treatment: Myrbetriq 25 milligrams 
The insurer denied Myrbetriq 25 milligrams.
The determination is overturned.

The patient was diagnosed with overactive bladder. Myrbetriq 25 milligrams (mg) tablets were prescribed. Oxybutynin caused dizziness and Toviaz was ineffective per the provider's letter.
At issue is whether the formulary drug Toviaz will be or has been ineffective, would not be as effective as the non-formulary drug Myrbetriq Tab 25 mg, or would have adverse effects.

Yes. The physician documented that Toviaz was ineffective. Therefore, the formulary medication Toviaz has been ineffective and would not be as effective as the nonformulary drug Myrbetriq 25 mg tablet. 
Myrbetriq is Food and Drug Administration (FDA) approved for treatment of overactive bladder and is supported by published literature as efficacious for treatment of this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status asthmaticus.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient has a history of asthma and pelvic inflammatory disease. She presented to the hospital a day after she signed out Against medical advice (AMA) with complaints of (c/o) shortness of breath (SOB) and wheezing. The patient reported using Marijuana and vaping. The patient has had multiple Emergency department (ED) visit admissions to the hospital for the same symptoms.  Vital signs (V/S) at presentation temperature 98.5, blood pressure 108/76, heart rate 112, respiratory rate 19, and oxygen saturation at 97 % (percent) on room air. The patient was in no acute distress. Diffuse wheezing was noted on the lung exam.

The patient was treated with bronchodilators via nebulizer, intravenous (IV) Magnesium, oral (PO) steroids. The patient was also restarted on antibiotics for pelvic inflammatory disease (PID) - Cefoxitin and PO Doxycycline.

The patient had a chest X ray which did not reveal any infiltrates.

The patient was admitted to hospital for asthma exacerbation and PID. As per the history and physical the temperature was 98.5 blood pressure was 110 / 72 heart rate was 92 respiratory rate was 18, and oxygen saturation was 98% on room air. The patient's peak expiratory flow (PEF) was 270. The patient improved with treatment. A few hours after admission she signed out AMA as she said she had to be at work. This patient did not need acute inpatient hospitalization. 
She could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission, was afebrile and hemodynamically stable. oxygen saturation was 97-98 % on room air. Chest X ray was negative for pneumonia.

This patient could have been discharged home on oral steroids, bronchodilators, and oral antibiotics for pelvic inflammatory disease after a period under observation. This patient signed out against medical advice a few hours after admission.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.