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

Diagnosis: Kidney Failure
Treatment: Kidney transplant
The insurer denied: Kidney transplant
The denial is overturned

The patient is an adult female with kidney failure secondary to diabetic nephropathy and the treating physician requested kidney transplant. 

The kidney transplant is medically necessary. 

This is a patient with end stage renal disease without reversible cause and no contraindication to kidney transplant. This request is medically necessary per evidence-based literature. A systematic review of 110 studies encompassing almost 2 million patients concluded that kidney transplant was associated with better quality of life, fewer cardiovascular events, and lower long-term all-cause mortality as compared to chronic dialysis. [1] 
A study of 960 elderly (older than 65 years, mean age 71 years) propensity-matched patients with renal failure treated with home dialysis or renal transplant found a 4.7-fold higher mortality risk among the patients treated with home dialysis.[2]
Cadaveric and expanded criteria donor kidneys are appropriate when living donors are not available and for the elderly in whom the graft may last the lifetime of the recipient. [3] 
Therefore, the requested kidney transplant is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient presented with nausea, vomiting, and abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The lipase was initially mildly elevated but on repeat was normal. Both an abdominal ultrasound and computed tomography (CT) scan revealed a normal pancreas. The toxicology screen was positive for cocaine. She was diagnosed with pancreatitis secondary to alcohol use. Intravenous (IV) fluids and pain medications were given. She was then able to tolerate a diet. 

Clinical indications for admission for Pancreatitis per Milliman Care Guidelines (MCG M-250) include having 2 of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and findings on imaging of acute pancreatitis. In this case there was mild elevation of the lipase. However, on the repeat exam the lipase was normal. There was also no indication of pancreatitis on the ultrasound or CT scan. In addition, the patient did not have hemodynamic instability, severe dehydration, acute renal failure, altered mental status, or a severe electrolyte abnormality. She responded to the IV hydration and pain medications and was then able to tolerate a diet. 

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

This patient had abdominal pain and vomiting with a transient elevation of the pancreatic enzymes. She required IV hydration and pain medications, but this could have been given in the emergency room (ER) with observation status. She did not meet MCG criteria for admission for Pancreatitis or Undiagnosed Abdominal Pain. 

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Failing tooth restoration

Treatment: Tooth-colored cap (crown) for tooth #30

The insurer denied coverage for tooth-colored cap (crown) for tooth #30

The denial is upheld

 
Upon review of the documentation provided which includes copies of undated bitewing and periapical radiographs, undated full mouth series radiographs, dental history record and note, medical history record and insurer correspondence, it appears that this patient presented to the dentist for care involving tooth #30. The treating dentist recommended a full coverage crown for #30, presumably due to failing preexisting direct placement restoration. The insurer has denied these services stating there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service. The documentation is insufficient to approve treatment and therefore the service does not meet medical necessity criteria. The patient is appealing.

The only objective documentation provided for review is copies of radiographs. The dental record documentation provided for review does not include rationale for replacing the preexisting restoration. There are no other relevant treatment records provided for review. It appears that there is no evidence of fracture or other pathology specifically affecting #30 based on the images provided for review. There does not appear to be any radiographic evidence of caries and the existing restoration does not appear to be failing. The radiographs do not substantiate the requested dental service as enumerated above and therefore the crown is deemed not medically necessary.

Uphold denial of coverage for crown on tooth number 30 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment.

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 tooth-colored cap for tooth #30 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease
Treatment: Increase Personal Care Aide (PCA) Services 5 Hours a day 7 Days a Week for a Total Amount of 35 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services 5 Hours a day 7 Days a Week for a Total Amount of 35 Hours per Week
The denial is upheld.

The patient is an elderly female. She has Parkinson's disease, osteoarthritis, asthma, weakness, and hypothyroidism. She lives alone. Denial of increase personal care aide (PCA) services 5 hours a day 7 days a week for a total amount of 35 hours per week is being appealed. The plan approved PCA (personal care aide) 4 hours per day, 7 days a week for a total of 28 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, shopping, transportation, and lower body dressing; extensive assistance with managing medications, bathing, personal hygiene, upper body dressing, walking, locomotion toileting, and bed mobility; set-up with managing finances and phone use; and independent with eating. The patient has bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed on six months earlier, there has been no significant decline in functioning.

The Increase Personal Care Aide (PCA) Services 5 Hours a day 7 Days a Week for a Total Amount of 35 Hours per Week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase personal care aide (PCA) services 5 hours a day 7 days a week for a total amount of 35hours per week is being appealed. The plan approved PCA (personal care aide) 4 hours per day, 7 days a week for a total of 28 hours per week.
This patient has Parkinson's disease. Uniform Assessment System (UAS) evaluation completed recently shows she requires assistance with all ADLs (activities of daily living) except managing finances, phone use and eating. She has bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation six months prior, there has been no significant decline in functioning. The information provided does not support that the patient's needs cannot be met with the current PCA (personal care aide) services. The information provided does not support that the patient has continuous needs. PCA (personal care aide) is not indicated for supervision or when no tasks are being performed. The approved PCA (personal care aide) 28 hours per week is sufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The requested increase in services to 35 hours per week is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Low Back Pain.
Treatment:  Thermal destruction of intraosseous basivertebral nerve - including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).

The insurer denied thermal destruction of intraosseous basivertebral nerve - including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).  The denial is upheld.

The patient is a female 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 multiple medications including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. The patient's physical exam does not reveal any neurological injury.

The health plan should not cover thhe requested health service.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is not likely to be more beneficial than standard treatments.
The patient is a female 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 multiple medications including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. The patient's physical exam does not reveal any neurological injury.

The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown effective in RCT (randomized controlled trials) with 5 year results. The Intracept procedure (interosseous basovertebral 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 is typically use 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, the patient in this case is not documented to have 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 in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Low Back Pain.
Treatment:  Thermal destruction of intraosseous basivertebral nerve - including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).

The insurer denied thermal destruction of intraosseous basivertebral nerve - including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).  The denial is overturned.

The patient is an adult female. The patient presented with a history of low back pain. The patient is status post epidural steroid injection without relief. The pain is constant, aching, sharp, stabbing radiating to the buttocks, right hip and intermittently wraps to the right groin. The pain is aggravated with flexion, prolonged sitting and standing. Exam of the patient's lumbar spine revealed decreased range of motion with facet loading positive, and pain with flexion. The patient's diagnosis includes lumbar spondylosis, lumbar radiculopathy, vertebral genic low back pain.

The health plan's denial of coverage noted, "This service has not been found to be helpful for your condition. Therefore this service is not covered by your plan. Please speak to your provider about options for treatment."

Per the appeals letter, the patient has a history of chronic low back pain, due to degenerative disc disease resulting in development of vertebral genic pain identified by endplate Modic changes on MRI (magnetic resonance imaging). The patient has pain more than six months and has failed treatments for more than six months. Treatments include acupuncture, injection, epidural steroid injection, massage therapy, medial branch block, physical therapy, radiofrequency ablation and trigger point injections. The patient has also tried Cymbalta, Flexeril, gabapentin, ibuprofen, Lyrica, Mobic, Percocet and tramadol.

The health plan should cover the requested health service.

Based on the provided documentation, the requested interosseous basivertebral radiofrequency ablation is considered medically appropriate in this case. The patient has a history of continued back pain despite prior conservative treatments including activity modification, physical therapy, acupuncture therapy, trigger point injections, epidural steroid injections, medial branch block, as well as radiofrequency ablations and  medications. The patient continues to be symptomatic with positive findings on exam as well as on imaging with moderate changes. The requested procedure is approved by the FDA (United States Food and Drug Administration) for Modic type changes on MRI (magnetic resonance imaging). 

The requested health service is more beneficial. Given that the patient has tried and failed all other treatments, this would be the next step that would be recommended in regard to the patient's symptoms and findings on exam and imaging.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Low Back Pain.
Treatment:  Thermal destruction of intraosseous basivertebral nerve - including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).

The insurer denied thermal destruction of intraosseous basivertebral nerve - including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).  The denial is overturned.

The patient is an adult female with chronic low back pain, which has not responded to multiple treatments including acupuncture, medication management with Cymbalta, Flexeril, Gabapentin, Ibuprofen, Lyrica, Mobic, Percocet and Tramadol, and injections (lumbar epidural steroid injections, medial branch block, massage therapy, physical therapy, lumbar radiofrequency ablations, and trigger point injections). The pain has had a significant impact upon the patient's ADLs (activities of daily living), such as sitting and standing. She had an MRI (magnetic resonance imaging), which demonstrates degenerative endplate changes consistent with Modic changes at disc spaces L (lumbar) 4 and L5, confirming vertebrogenic mediated low back pain 
involving the L4 and L5 vertebrae.

The health plan should cover the requested health service.

The patient is an adult female with vertebrogenic mediated chronic low back pain confirmed by MRI (magnetic resonance imaging) findings in the lumbar spine, which has not responded to appropriate conservative management. The patient meets the inclusion and exclusion criteria for the thermal destruction of the intraosseous basivertebral nerves, or the Intracept procedure. The Intracept procedure is FDA (United States Food and Drug Administration) approved, and there is enough data in the medical literature to show it is safe and effective in the treatment of vertebrogenic low back pain. A prospective, randomized, multi-center study by Khalil et al. in 2019 and another prospective, randomized, multi-center study done by Fischgrund also in 2019 both presented high quality evidence of efficacy and safety of the procedure.

The requested treatment is more beneficial than any standard treatment for the patient's condition or disease.

The standard treatments including acupuncture, medication management with Cymbalta, Flexeril, Gabapentin, Ibuprofen, Lyrica, Mobic, Percocet and Tramadol, and injections (lumbar epidural steroid injections, medial branch block, massage therapy, physical therapy, lumbar radiofrequency ablations, and trigger point injections) were all tried and ineffective. The thermal destruction of the intraosseous basivertebral nerves, or the Intracept procedure, is the only indicated treatment left.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: alopecia areata totalis.
Treatment: Upadacitinib (Rinvoq).
The insurer denied Upadacitinib (Rinvoq). 
The health plan's determination is upheld.

The patient is a male with moderate to severe atopic dermatitis, as well as alopecia areata totalis. The patient has tried and failed topical clobetasol, mometasone, and fluticasone. The patient has lost all scalp and body hair with the exception of for some scant eyebrow/eyelash hair. The patient has extremely painful and itchy and erythematous plaques of the trunk, scalp, and extremities. Photographic documentation confirms the extensive hair loss.

Upadacitinib (Rinvoq) is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, either to tacrolimus ointment or to one of the standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil. The patient also has no documented treatment failure with, or true medical contraindication to, either phototherapy or to biologic agents more newly-approved for this condition (Dupixent or Adbry).
Rinvoq is not proven to be superior to all other alternatives as per comparative, controlled studies, and is only Food and Drug Administration (FDA) -approved for second-line systemic therapy behind the other, aforementioned systemic therapies. Rinvoq is not FDA-approved for moderate to severe atopic dermatitis. Therefore, as per current medical literature, the requested Rinvoq is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: shortness of breath
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented to the emergency department with cough and shortness of breath. He was well until 1 week prior to presentation when he developed an ear infection. He was prescribed antibiotics at that time, and was also noted to have a cough and was prescribed albuterol and ipratropium. He completed the antibiotics, but 2 days prior to presentation his cough worsened and he developed increased work of breathing that was not relieved with albuterol and ipratropium. He also had irritability and fussiness, and had one episode of post-tussive emesis. He was therefore brought to the emergency department for evaluation.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young boy who presented with cough and increased work of breathing. He received appropriate and intensive treatments in the emergency department, including bronchodilators and corticosteroids, but he continued to have retractions and wheezing. He therefore required hospital admission for bronchiolitis with asthma, for frequent albuterol nebulized therapy (initially every 2 hours), along with close monitoring and additional treatment as needed.
The decision making at the time of admission for this patient was consistent with his young age, the presence of respiratory distress and wheezing that persisted despite appropriate and intensive treatments at home and in the emergency department, and the need for ongoing, frequent bronchodilator treatments along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ear/Nose/Throat/Other/left peritonsillar abscess
Treatment: Inpatient Stay
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is upheld.

The patient is a female with a concern for a left peritonsillar abscess. There were no breathing concerns. Vital signs were stable, and the patient was afebrile. Ear, nose, and throat (ENT) specialists attempted drainage at the bedside, but it was unsuccessful. The patient was admitted for intravenous (IV) antibiotics and steroids. She responded quickly to medical management and spent 2 nights in the hospital.
At issue is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No. The patient had a peri-tonsillar phlegmon (if she had an abscess then pus would have been drained when ENT did bedside evaluation).
Peri-tonsillar phlegmon/abscess very rarely requires inpatient admission. Most patient can be managed under an alternate status, as IV medication is the only medical therapy needed other than pain control. Although patients have universally airway swelling, most do not require any intervention. Inpatient admission is only needed for patients with peritonsillar abscess who have difficulty breathing or who have a prolonged inability to swallow that has not responded to medical management.
Inpatient admission was not required for this patient. This patient had stable vital signs, no difficulty breathing, and responded quickly to IV antibiotic/steroid management. There was no documented clinical concern for airway embarrassment, as patient was breathing comfortably and had stable vital signs. There were also no clinical signs of systemic infection.
The patient could have been managed under an alternate level of care.

No. The patient had a peri-tonsillar phlegmon (if she had an abscess then pus would have been drained when ENT did bedside evaluation).
Peri-tonsillar phlegmon/abscess very rarely requires inpatient admission. Most patient can be managed under an alternate status, as IV medication is the only medical therapy needed other than pain control. Although patients have universally airway swelling, most do not require any intervention. Inpatient admission is only needed for patients with peritonsillar abscess who have difficulty breathing or who have a prolonged inability to swallow that has not responded to medical management.
Inpatient admission was not required for this patient. This patient had stable vital signs, no difficulty breathing, and responded quickly to IV antibiotic/steroid management. There was no documented clinical concern for airway embarrassment, as patient was breathing comfortably and had stable vital signs. There were also no clinical signs of systemic infection.
The patient could have been managed under an alternate level of care.