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

Diagnosis: Lumbar back pain.
Treatment: Intracept procedure (Current Procedural Terminology (CPT) code 64628).
The insurer denied coverage for Intracept procedure (CPT code 64628).
The denial is upheld.

This is a patient with a history of back pain. The patient had magnetic resonance imaging (MRI) which demonstrates Modic type I degenerative endplate signal changes at lumbar (L) 2-3. The patient had a physician office visit for chronic vertebrogenic low back pain and the plan is for a basivertebral nerve ablation, Intracept procedure. 

It is unclear whether Intracept procedure (CPT code 64628) is considered more beneficial for this patient's diagnosis. There are studies but overall results at the very best note 65 percent (%) improvement of subjective parameters. There are no guides nor recommendations made by the practicing neurosurgical or orthopedic community. The Food and Drug Administration (FDA) has granted approval for marketing but no statement regarding efficacy. 

No pain generator has been defined. This person has been treated for myalgia (trigger point injections), disc disease, and radiculopathy (epidural steroid injections). Her imaging studies show multilevel disc disease with several herniations. Her physical examination varies with global areas of tenderness and restricted motion (i.e. general subjective complaints). Simply stated there is no indication that vertebrogenic pathology is causing her pain. 

The procedure is invasive, and complications have occurred including infection, instrument breakage and retroperitoneal hematoma. The requested service is not likely to be more beneficial than any of the standard procedures for this patient. The operation is not recognized by practicing neurosurgeons nor spine surgeons. There are no National Organizations which provide guidelines or indications. The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

The procedure is essentially a thermoablation performed within the vertebral body. 
There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. 

In summary, the denial of the Intracept procedure (CPT code 64628) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heavy vaginal bleeding.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female who had undergone a medical termination of pregnancy.  She presented with complaints of heavy vaginal bleeding where she was soaking pads hourly.  Her hemoglobin went from 11.4 to 10.5.  She had an ultrasound revealing a 14-millimeter endometrial stripe with blood clots in the uterus.  The decision was to admit her.  She was given intravenous access and fluids.  She was taken to the operating room and a dilation and curettage (D&C) was performed.  The diagnosis was retained products of conception.  Her bleeding improved post-surgery, her vitals were stable, and she was discharged home within 24 hours.

The hospital stay is denied.  This is being appealed.

The proposed inpatient hospital admission was not medically necessary.

According to the American College of Obstetricians and Gynecologists (ACOG):
"The ERAS (enhanced recovery after surgery) principles represent an evidence-based approach to surgical management that challenges traditional surgical management paradigms. The use of ERAS pathways has resulted in more rapid surgical recovery, shorter length of stay, greater patient satisfaction... when compared with traditional approaches. These benefits have been replicated across the spectrum of gynecologic surgeries, including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the ERAS program requires collaboration from all members of the surgical team. Successful ERAS pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems, and the use of ERAS pathways should be strongly encouraged within institutions."

An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.  

The patient in question was taken to the operating room and underwent an uncomplicated procedure for vaginal bleeding following a medical termination.  She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea post-surgery.   This care however did not require acute care.  Her vitals were stable, her bleeding was minimal, and pain was minimal.  The same care could have been done in an observation status.  Later, on the post operative day, the patient was ready for discharge requiring less than a 24 hour stay.  Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Early acute cholecystitis.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with history of gastric sleeve who presented with early acute cholecystitis. The patient underwent laparoscopic cholecystectomy. She was discharged the same day after her surgery. Her white blood cell (WBC) was normal, and her liver functions tests (LFTs) were normal. The operating report showed edematous gallbladder.

The proposed inpatient hospital admission was not medically necessary.

The patient underwent inpatient admission for uncomplicated acute cholecystitis. Uncomplicated acute cholecystitis is generally treated at a lower level of care unless there are contributing factors such as complications or comorbidities that warrant inpatient admission.  This patient had no issues after the surgery or medical issues prior that necessitated further inpatient monitoring.  The patient had a white blood cell (WBC) count of four and only had evidence of early acute cholecystitis. The patient was discharged without complications. There was no indication for inpatient admission.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Genitourinary/ Kidney Disorder.
Treatment: Inpatient Hospital.
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned in part. 

The patient is a male with a history of a right staghorn calculus, who underwent right percutaneous nephrolithotomy (PNCL). The patient had residual stone at the end of the case, and the plan was to return for a second look procedure. A computed tomography (CT) scan revealed residual stone, for which the patient underwent an interventional procedure  for internalization of the nephroureteral access. His hemoglobin was 11.0, down from 12.4. 
At issue is the medical necessity of the inpatient admission.
The health plan's determination is overturned in part.
The requested health service/treatment of inpatient admission was medically necessary for this patient for part of the stay. It was reasonable for the patient to stay through post-operative day 2. The patient underwent an uncomplicated percutaneous nephrolithotomy, with plans for an intervention (internalization of nephroureteral stent). The patient meets the attached Milliman Care Guidelines (MCG) Urological Procedure guideline for admission as the patient underwent two urological procedures - percutaneous nephrolithotomy, then an internalization of that access in interventional radiology. In review of the documentation, there did not appear to be an appropriate reason to board the patient the last additional day. Therefore, the inpatient admission was medically necessary through post-operative day 2.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cognitive decline
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for depression, liver cirrhosis, and chronic abdominal pain who was referred to the emergency department by her outpatient psychiatrist for psychiatric evaluation due to worsening depression and consideration for possible electroconvulsive therapy. The chief complaint at the time of admission was reported as depression and subacute cognitive decline.

The inpatient hospital stay was not medically necessary for this patient.
The patient had no documentation of hemodynamic instability, persistent altered mental status, respiratory distress, or focal neurologic deficits. The patient's physical exam was unremarkable and there was no reason to keep the patient in the hospital after evaluation by the emergency department physician.
The only reason that the patient stayed in the hospital was a concern for the safety of the patient at home. The laboratory evaluation that was performed while in the hospital was unremarkable. The patient remained afebrile. It was unclear why the patient was treated for possible spontaneous bacterial peritonitis when she did not have ascites.
Furthermore, the patient's cognitive decline and depression were not associated with suicidal or homicidal ideations.
Neither the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care. Admission for a short period of observation in order to ensure safe disposition was most appropriate, given the clinical circumstances.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Missing Tooth/Teeth
Treatment: Dental/Orthodontic Procedure/dental treatment: surgical placement implant for teeth #'s 2, 3, 4, 13, 14, 20, 21.

The health plan denied the requested dental treatment: surgical placement implant for teeth #'s 2, 3, 4, 13, 14, 20, 21 as not medically necessary. 

The health plan's determination is overturned.

This is a female who was denied implants to replace teeth #2, #3, #4, #13, #14, #20, & #21, as medical necessity criteria were not met.
At issue is the medical necessity for the requested health service/treatment of dental treatment surgical placement implants for teeth #'s 2, 3, 4, 13, 14, 20, and 21.

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

Yes. Implants are the standard of care to replace missing teeth. The options in this case to restore function are implants or a partial denture. Implants are the best option. The options to restore function in this case are removable dentures or implants. Implants are the best choice. A partial denture has been shown to lead to the loss of adjacent teeth and have less chewing efficiency than implants. Implants are the standard of care and are much more efficient than a partial. They are the closest thing to natural teeth, preserve the bone and are not susceptible to caries.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Tremfya 100mg/ml (milligrams per milliliter) SC (subcutaneous) SOPN (Solution Pen-injector). 

The insurer denied: Tremfya 100mg/ml (milligrams per milliliter) SC (subcutaneous) SOPN (Solution Pen-injector). 

The denial is overturned. 

The patient is an adult female with psoriasis to the scalp and abdomen, Physician Global Assessment (PGA) score of three, treated with topicals. The provider is requesting Tremfya. The health plan requires a trial of systemic therapy, specifically cyclosporine. The provider has stated the patient cannot use methotrexate and acitretin as she is of childbearing potential. The provider has also stated that the patient has hypertension and cannot use cyclosporine. 

The proposed treatment with Tremfya is medically necessary. 

Cyclosporine would not be an appropriate choice for a patient with hypertension, as well as for a female of childbearing potential. Tremfya is an approved, appropriate and effective medication for psoriasis. A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Based on the randomized controlled trials, guselkumab maintains high levels of clinical response and improvement in patient-reported outcomes through five years in patients with moderate-to-severe psoriasis (Reich 2021).
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: foreign body in leg
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented to the emergency department (ED) with a complaint of a foreign body in the right leg. The patient reported associated leg pain and swelling. The patient had normal vital signs at the time of presentation. His ED evaluation with physical exam, imaging, and lab data identified a 0.7 centimeter (cm) metallic density in the proximal right leg.

Per the medical records submitted, the inpatient hospital admission was not medically necessary. The care and treatment provided could have reasonably and safely been provided at a lower level of care during this time.
This patient's clinical needs (ED assessment, lab data, imaging, orthopedic consultation, and serial exams) could have been satisfied at a lower level of care. There was no vascular compromise, infection or compartment syndrome. The patient did not require any acute surgical intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac Ablation for Arrhythmia
Treatment: Inpatient Admission
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

This case involves a female with a history of chronic systolic heart failure due to nonischemic cardiomyopathy, a left ventricular ejection fraction (LVEF) of 40%, non-obstructive coronary artery disease (CAD), hypertension, hyperlipidemia, and symptomatic premature ventricular contractions (PVCs). The patient underwent elective electrophysiologic (EP) study with 3D (3dimensional) mapping of the successful left sided PVC ablation without complications. The patient was admitted to telemetry service under inpatient level of care for monitoring overnight, 4-hour bed rest, clinic monitoring, initiation of anticoagulation with Apixaban, and repeat echocardiogram post procedure. An echocardiogram report demonstrated a mildly reduced LVEF, no significant valve disease, and trivial pericardial effusion. The patient remained hemodynamically stable, asymptomatic, and was discharged home the following day in stable condition.

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

Inpatient level of care was medically necessary, appropriate and in the best interest for the safety of this patient for the following reasons.

Inpatient admission overnight was medically appropriate, necessary, and in the best interest for the safety of this patient, given the long duration of the procedure (approximately 4 hours) that was the left heart in location increasing the risk of potential complications, and for monitoring after intravenous (IV) fluid administration in this patient with known heart failure. For these reasons, inpatient level of care would be recommended and is supported by the 2019 Heart Rhythm Society/European Heart Rhythm Association/Asian Pacific Heart Rhythm Society/Latin America Heart Rhythm Society (HRS/EHRA/APHRS/LAHRS) expert consensus statement on catheter ablation of ventricular arrhythmias. [1]

The patient was at increased risk for periprocedural complications including a heart failure exacerbation, bleeding, vascular damage and cardiac tamponade, given her history of heart failure, left-sided location of the ablation procedure, intravenous fluid administration and anticoagulation initiation, post procedure. Monitoring post PVC ablation under a lower level of care would not have been safe in this case.

I recommend that the health plan determination be overturned on the grounds inpatient level of care was medically appropriate and necessary for telemetry and clinical monitoring overnight after a left-sided PVC ablation in the context of underlying cardiomyopathy increasing the risk of peri-procedural complications. Evaluation and monitoring post ablation under a lower level of care would not have been safe in order to achieve optimal patient outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is: Upheld.

The patient is a previously healthy male who presented to the hospital emergency department (ED) with a history of progressively worsening abdominal pain and anorexia. Evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was 53/minute in the ED. Lab data identified a white blood cell (WBC) count of 4.5 thousand (K). CT scan yielded the diagnosis of uncomplicated acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics.
The patient underwent appendectomy performed via laparoscopy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The appendix was inflamed, but not perforated. He was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. He was discharged home.
The subject under review is the medical necessity for an inpatient hospital admission.

The health plan's determination is upheld.

Acute inpatient hospital admission was not medically necessary for this patient.
This patient presented to the ED with abdominal pain. The evaluation with examination, lab data, and CT scan established the presumptive diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and appendectomy performed. The early post-surgical course was uncomplicated, and the patient was clinically stable for discharge from the hospital following surgery.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Swallowing Difficulty
Treatment:  Inpatient Hospital Admission

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

The patient is a female with a history of hypertension, asthma, multiple allergies, thyroid disease, swallowing difficulties, and anxiety. Late in the evening she presented to the emergency room with the sudden onset of a sense of throat swelling, scratchy throat, swallowing difficulties, and voice changes. The vital signs were normal, and she was awake and alert. Physical exam showed a raspy voice and "mild fullness of the left oropharynx." There were no clinically relevant laboratory abnormalities. The soft tissue x-ray of the neck was unremarkable. The patient was treated in the emergency department (ED) with corticosteroids and antacids, which provided relief of her symptoms. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with nebulizer treatments and oral acetaminophen as needed. The ear, nose, and throat (ENT) consultant evaluated the patient, and found only mild hoarseness with a normal epiglottis and good vocal cord mobility on laryngoscopy. It was concluded that her throat symptoms were most likely due to gastroesophageal reflux disease (GERD). A proton pump inhibitor (PPI) and reflux precautions were recommended. A chest x-ray showed hyperinflated lungs without acute pulmonary pathology. The remainder of the stay was clinically uneventful, and the patient was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested inpatient hospital admission was not medically necessary for this patient.

Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no stridor, hypoxia, hemodynamic instability, mental status changes, or severe metabolic disarray. The laryngoscopy, which is an outpatient procedure, did not show any worrisome findings. The services provided - ENT consultation with laryngoscopy, nebulizers, oral medications - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Services (PCS): 24 hours/day, 7 days/week, split shift - total of 168 hours
The insurer denied the PCS: 24 hours/day, 7 days/week, split shift - total of 168 hours.
The health plan's determination is overturned.

The patient is a female with past medical history of chronic kidney disease, osteoarthritis, dementia, gout, urinary incontinence, bowel incontinence, hypertension, breast cancer, gastroesophageal reflux disease (GERD), congestive heart failure, coronary artery disease, diabetes mellitus type 2, depression, anxiety, insomnia, and osteoporosis who had been assigned personal care aide (PCA) services.

Personal Care Services (PCS): 24 hours/day, 7 days/week, split shift - total of 168 hours are medically necessary for this patient.

There is documentation from the patient's medical providers of medical necessity of split shift services due to the need for frequent repositioning in the overnight hours at least every 2 hours. In addition, both providers noted the patient required frequent changing of incontinence supplies due to urinary and bowel incontinence. The patient requires total assistance with transfer toilet and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs in the overnight hour would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, PCA services 24 hours/day, 7 days/week, split shift, to total 168 hours/week are medically necessary for this patient. PCS are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.