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

Diagnosis: Dementia, depression, hypertension, osteoarthritis, congestive heart failure

Treatment: increase in personal care services to 12 hours per day, 7 days per week

The insurer denied coverage for increase in personal care services to 12 hours per day, 7 days per week

The denial is overturned.

This is a geriatric patient with a history of dementia, depression, hypertension, osteoarthritis, and congestive heart failure (CHF). According to the most recent Uniform Assessment System (UAS), the patient is alert with periods of forgetfulness and confusion. The patient requires total dependence for ordinary housework. Maximal assistance for meal preparation, managing medications, bathing, dressing lower body, and toilet use. Extensive assistance for personal hygiene, dressing upper body, walking and transfer to and from the toilet. The patient often forgets to use a walker and has to be prompted each time. The patient has infrequent incontinence of bowel and has daily incontinence of bladder with some control. The patient had a fall. 

The medical records show continued deterioration to this elderly person. There have been frequent hospital admissions for several different types of medical conditions such as urinary tract infection, CHF, high platelets, and falls. The records show progression to loss of independence and need for constant follow-up. The patient has poor mobility and mental status, is incontinent, requires assistance with most activities and medication monitoring, and is unlikely to maintain the current status based upon recent medical services. The proposed 12 hours per day for 7 days are necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for increase in personal care services to 12 hours per day, 7 days per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld.

The patient presented with right lower quadrant (RLQ) abdominal pain. He was afebrile and the vital signs were stable. He did not have peritoneal signs. The white blood cell (WBC) count was 11.4. An abdominal computed tomography (CT) scan showed mild periappendiceal fat stranding that was suggestive of acute appendicitis. There was no fluid collection. The lactic acid was elevated. He was given intravenous (IV) hydration and antibiotics and improved. 

The hospital and insurance company have both referenced Milliman Care Guidelines (MCG) guidelines for Gastroenterology (GRG: MG-GAS). The current guideline states that acute appendicitis with planned nonoperative management or interval appendectomy is an indication for admission if there is a hemoperitoneum. The patient did not have a hemoperitoneum. An acute intra-abdominal process is also an indication for admission if there is hemodynamic instability, peritoneal signs, mesenteric ischemia, or free air. The patient did not have these conditions. 

This patient had RLQ abdominal pain without peritoneal signs. He received IV hydration and antibiotics and improved rapidly. He could have received this treatment with observation status. He did not meet MCG criteria for admission for Gastroenterology. 

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

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sinusitis
Treatment: Budesonide nebulizer suspension
The insurer denied coverage for Budesonide nebulizer suspension
The denial is overturned.

Clinical notes reported the patient was being seen for sinonasal complaints. Symptoms included nasal congestion, difficulty breathing through nose, postnasal drip, decreased sense of smell, rhinorrhea, and itchy eyes. Past medical history was significant for polypectomy and functional endoscopic sinus surgery over 20 years ago. Current treatment included Zyrtec, azelastine, eyedrops, and montelukast daily as well as prednisone/antibiotics when experiencing yellow drainage from nose. Last use of prednisone was 3 months prior. The patient was also using Advair for asthma which was well controlled. Treatment plan included using budesonide rinse in each nostril daily for chronic sinusitis.

A follow up clinical note revealed the patient reported worsening symptoms for the past week to include thick green/yellow drainage from both nostrils. There was also nasal congestion, postnasal drip, and nonproductive cough. The patient was using budesonide nasal rinses. Treatment plan was to continue with current medical regimen.

A letter reported the patient has been using budesonide rinses since over 3 years ago with well-maintained symptoms. A letter from the patient stated the use of budesonide rinse on a daily basis has eliminated the need for antibiotic use.

Scientific literature supports that nasal irrigation with budesonide is an effective postoperative treatment for chronic rhinosinusitis with asthma, which recurs frequently, reducing the oral steroid intake.

In this case, the patient has a history of chronic rhinosinusitis and asthma. The patient also has a history of polypectomy and functional endoscopic sinus surgery. The patient has been utilizing budesonide for over 3 years with reduction in antibiotic use. Continuation would be supported. Up to Date has also noted the effectiveness of this this approach.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

Budesonide nebulizer suspension does not have final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for Budesonide nebulizer suspension.

Budesonide nebulizer suspension is the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The denial of Budesonide nebulizer suspension and coverage for the requested treatment should be overturned.

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sinusitis
Treatment: Budesonide nebulizer suspension
The insurer denied coverage for Budesonide nebulizer suspension.
The denial is overturned.

The patient has a history of sinusitis. The patient has complaints of nasal congestion, difficulty breathing, postnasal drip, and rhinorrhea. Past treatment included polypectomy and functional endoscopic sinus surgery. It was noted that the patient utilized prednisone and antibiotics when experiencing drainage. The patient was recommended to start budesonide rinse daily.

The patient reported worsening symptoms. There was report of drainage from nostrils. The patient continued to use budesonide nasal rinses.

Appeal letter from the provider stated that the patient's symptoms had been well-maintained since starting budesonide rinses over three years ago. Letter from the patient stated the use of budesonide rinse on a daily basis has eliminated the need for antibiotic use. The use of budesonide for sinusitis is supported as an off-label use. Current literature demonstrates that budesonide is safe and effective.

There is scientific evidence in peer-reviewed literature that supports a result of improvement in health outcome.

Budesonide nebulizer suspension does not have final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for Budesonide nebulizer suspension.

Budesonide nebulizer suspension is the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services.

In this case, the requested medication is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The denial of Budesonide nebulizer suspension and coverage for the requested treatment should be overturned.

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sinusitis
Treatment: Budesonide nebulizer suspension
The insurer denied coverage for Budesonide nebulizer suspension.
The denial is overturned.

The patient presented with nasal obstruction. The patient's past medical history includes sinus surgery 20 years ago. The patient's current medication regimen includes Astelin, montelukast, saline irrigations with budesonide, and Zyrtec. Symptoms include congestion and post nasal drip. Immunotherapy has been trialed, with no relief. The physical examination was grossly normal. 

Budesonide therapy is supplementary to the other medications the patient is using. The benefit and safety profile are well documented in the literature. The request should be approved especially given that the patient has been using this medication for 2 years with great benefit. Switching medication would jeopardize the patient's clinical stability. The literature supports the beneficial usage of budesonide in saline irrigations for those with sinus complaints. 

According to Kang, et al., (2017), "Nasal irrigation with budesonide is an effective postoperative treatment for chronic rhinosinusitis with asthma, which recurs frequently, reducing the oral steroid intake."

Per Periasamy, et al., (2020), "This study adds evidence to the use of saline nasal irrigation in allergic rhinitis, but also demonstrates efficacy of the addition of budesonide to irrigations. Budesonide nasal irrigation thus appears to be a viable treatment option for allergic rhinitis."

Lastly, Tait, et al., (2018), "This study shows that budesonide in saline nasal lavage results in clinically meaningful benefits beyond the benefits of saline alone."

Budesonide nebulizer suspension does not need approval from regulatory bodies, in this instance.

This patient is a good candidate for Budesonide nebulizer suspension. It is not being used for inhalation. Rather, it is being used for sinus relief in saline irrigations.
  
Budesonide nebulizer suspension is the best available treatment for this patient at this time, as budesonide is very safe and effective for those with similar complaints and sinus surgery history.

The adverse risks are not increase over standard treatment.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.
  
In summary, the denial of  Budesonide nebulizer suspension should be overturned.

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: 64628 Thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The insurer denied: 64628 Thermal destruction of intraosseous
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The denial is upheld.

The patient is an adult female with low back and right leg pain. The patient has a history of L5-S1 microdiscectomy. She has tried epidural steroid injections, tramadol, and physical therapy. MRI (magnetic resonance imaging) of the lumbar spine shows history of left hemilaminectomy at L5-S1, a prominent central disc extrusion with inferior rightward migration and persistent contact of the right S1 and S2 nerve root, and degenerative endplate signal change at L5-S1.
The request for L5-S1 Intracept procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the Intracept procedure.

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 requested health service. 

The requested Intracept procedure is not more beneficial than any standard treatment for the patient's condition or disease.
Other standard treatment options may include non-opioid medications (i.e., NSAIDs [nonsteroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., repeat physical therapy, home exercise program, chiropractor treatments), and interventions (i.e., repeat epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The insurer denied: 64628 Thermal destruction of intraosseous
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The denial is upheld.

The patient is an adult female. The request is for Intracept procedure. Prior denial had noted that the procedure is considered investigational. The denial is being appealed.
Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease. This resulted in development of vertebral genic pain identified by degenerative endplate changes noted to be Modic on MRI (magnetic resonance imaging). The patient has had pain for greater than 6 months and failed treatment for greater than 6 months. Previous treatments include home exercise and physical therapy.
The patient presented with a history of back pain. The patient underwent epidural steroid injection and had a prior decompression on the left L5-S1 microdiscectomy. 
The patient has back pain, leg pain, and prominent back pain. The pain is 6/10. The patient has tried home exercises, stretching, and physical therapy for 6 weeks without relief. Diagnosis includes vertebrogenic chronic low back pain.

The health plan should not cover the requested Intracept procedure.

Based on the documentation provided, the request is not recommended at this time.
The requested Intracept procedure is not more beneficial.
Based on the documentation provided, the requested Intracept procedure is not considered medically appropriate in this case. Although the patient has a history of continued low back pain, there was no documentation of patient having tried and failed all prior conservative treatments, including medial branch blocks, as the patient has mostly axial pain. Additionally, it was noted that there were Modic type changes, but the MRI (magnetic resonance imaging) did not provide such evidence. As such, 
the requested Intracept procedure is not recommended at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient Emergency Admission
The insurer denied: Inpatient Emergency Admission
The denial is upheld.

The patient is an adult male who presented for what is documented to be an elective epilepsy monitoring unit stay. It was noted that he had progressively worsening episodes of emotional outbursts with confusion. The patient's last witnessed seizure was several years ago.  The rationale for the stay was to decrease the Depakote dose to provoke an event so that it could be characterized further. The health plan denied the request on the basis that the patient was not documented to be unstable, and services could have been provided at a lower level of care.

The proposed inpatient emergency admission was not medically necessary.

The service in question was an elective epilepsy monitoring unit admission. There was no documentation of acute seizure or concern for status epilepticus warranting the admission, which are Milliman Care Guideline indications for inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke

Treatment: Hospital admission

The insurer denied coverage for hospital admission

The denial is upheld

This case involves an adult patient who presented to the Emergency Department with complaints of dizziness and aphasia since the day prior. The patient also noticed right-sided facial asymmetry. Past medical history was significant for high blood pressure. Physical examination noted mild aphasia and right-sided facial symmetry. The National Institutes of Health Stroke Scale (NIHSS) score was a 2. A stroke code was activated and the treatment plan included imaging, labs, and a neurology consultation. A Computerized Tomography (CT) of the head and neck revealed no acute intracranial process. There were chronic ischemic changes including an old right posterior inferior cerebellar artery (PICA) infarct. The patient reported episodic tinnitus. The treatment plan was for follow-up included Magnetic Resonance Imaging (MRI) of the brain with admission to telemetry to include neurological checks. The neurology consultation reported the patient stated slurred speech was improved. A physical examination noted a mild right nasolabial fold asymmetry with no aphasia. The patient was not a candidate for Tissue plasminogen activator (tPA) or mechanical thrombectomy. The treatment plan was for an MRI and an admission to the stroke unit. An MRI of the brain was completed and revealed acute ischemia involving the left basal ganglia. The progress note stated that speech was the main focal deficit. Anticipated discharge was the following day. A discharge summary reported the patient was discharged to home to follow-up with neurology. 

Milliman Care Guidelines (MCG) recommends inpatient care for patients with acute ischemic stroke when there are neurological findings or need for inpatient care or monitoring. In this case, there was a lack of documentation of hemorrhagic transformation, altered mental status, dysphagia, significant arm or leg weakness, gait impairment, hemodynamic instability, or cardiac arrhythmias of immediate concern. There was dizziness, right-sided facial asymmetry, and aphasia initially; however, symptoms had largely resolved by the time of the neurology consultation. Imaging did reveal acute ischemia involving the left basal ganglia. However, treatment and workup could have been addressed under observational care. Given the submitted findings, there is a lack of clinical evidence to support inpatient admission. 

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

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dermatitis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Stay. 
The determination is upheld. 

The patient has a past medical history of hyperlipidemia who presented to the emergency department with a large rash on his head with associated burning sensation and swelling. The patient's vital signs were stable in the emergency department. Per the patient, two days prior to arrival, the patient dyed scalp and beard at the barber. While in the emergency department, he had a white blood cell count (WBC) of 11 and received cefazolin, doxycycline, and Benadryl. 

The patient was admitted to inpatient with suspected contact dermatitis with possible cellulitis. There was no concern for anaphylaxis given the patient had no evidence or complaints of shortness of breath, intraoral edema, or wheezing on exam. The patient stated that symptoms had worsened throughout the day, particularly swelling, and there was concern for superinfection. The patient stated there was no improvement with topical steroids. The rash began weeping yellowish liquid and edema also spread to his left upper eyelid. He did not have pain with extraocular movements or signs of compression of cranial structures and thus no concern for orbital cellulitis. However, given the increasing edema and high-risk location of the rash he was admitted. He received intravenous steroids and intravenous antibiotics and was discharged on oral steroids and oral antibiotics. 

The expert upheld the determination. 

The expert determined that there is not sufficient clinical documentation to support the medical necessity criteria of the health plan.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
inpatient hospital

Diagnosis: bowel obstruction
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a woman who presented to the emergency department (ED) with acute onset abdominal pain, nausea, and vomiting of several hours duration. Her past medical history was significant for resection of a pelvic desmoid tumor and prior lower abdominal hernia surgery. Her heart rate at the time of presentation was 57/minute. The abdomen was tender in the left lower quadrant and there was a ventral hernia in the left upper and lower quadrants. Her white blood cell (WBC) count was normal at 9.9. Potassium and renal function were normal per the basic metabolic panel. The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed dilated small bowel with a transition point to decompressed small bowel consistent with bowel obstruction. There was also a new left pelvic fluid collection.

The records support that inpatient admission was medically necessary, appropriate and consistent with medical standards. The submitted records support that this patient presented with acute onset of abdominal pain. She had pathology identified on CT scan that documented findings of small bowel obstruction. She was monitored with daily examination and surgical consultation. Her condition did gradually improve over 48 hours though the patient continued to have emesis. She reported less pain and there was improvement based on fluoroscopic imaging.
An inpatient designation was appropriate as the presenting condition, the CT imaging, the anticipated length of stay, and the intensity of service were consistent with an inpatient level of care. Inpatient admission was appropriate in this case as there was a high index of suspicion that her care would extend beyond an observation period. Her evaluation required that she not eat or drink initially. Her severity of pain and the pathology identified on computed tomography (CT) scan were such that her clinical condition was judged too severe to be within scope of observational care. This included severe pain requiring acute inpatient management, identification of etiology of the suspected obstruction, and failure to pass flatus, and signs of intestinal obstruction.