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

Diagnosis: Fever, Adenovirus. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is overturned. 

The patient is a male child with a medical history significant for Kawasaki disease who presented to the emergency department (ED) with a one-day history of a fever to 101.1 degrees Fahrenheit, two-day history of a headache, and same-day history of abdominal pain and vomiting. A right lower quadrant ultrasound was negative for free fluid but did not visualize the appendix. An abdominal computed tomography (CT) scan revealed a large number of small retroperitoneal and mesenteric lymph nodes and possible appendicolith with no evidence of acute appendicitis. A pediatric surgery consultation was placed with recommendations to evaluation other possible infectious causes. A chest x-ray was obtained and was normal. He was treated with Tylenol and Motrin, a normal saline bolus, and maintenance intravenous (IV) fluids, and admitted for serial abdominal exams. 
Admission orders included nothing by mouth with maintenance IV fluids, pediatric surgery consultation, serial abdominal exams, vital signs every four hours, Tylenol and Motrin as needed. Surgery recommendations included no acute surgical interventions, nothing by mouth with IV fluids, no antibiotics, serial abdominal exams, and complete infectious work-up. On follow-up, recommendations included advancing to a regular diet and discharge home when able. He continued to spike fevers. A viral respiratory panel was obtained, returning positive for adenovirus. He was encouraged to take a bland diet; Pepcid was added for new-onset epigastric pain. All cultures returned negative. He was deemed stable for discharge once his vomiting resolved. He was able to wean from intravenous (IV) fluids, and he was able to tolerate sufficient fluids and nutrition. At issue is the medical necessity of an inpatient admission. 
The inpatient admission was medically necessary. 
This male child presented with signs and symptoms consistent with acute appendicitis but imaging studies revealing only an appedicolith with numerous retroperitoneal and mesenteric lymph nodes. Further testing revealed infection with adenovirus. He continued with fevers and poor intake necessitating antipyretics and parenteral fluids for several days. Once he stopped vomiting and his appetite improved sufficiently, he was discharged home. His management was most consistent with an acute inpatient level of care. A lower level of care would not have been sufficient in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult female with cholecystectomy and cholecholithiasis status post endoscopic retrograde cholangiopancreatography (ERCP) 3 years ago. She presented with severe right upper quadrant (RUQ) abdominal pain x 1 week. The patient's white blood cell (WBC) count was 12.02. Computed tomography (CT) of the abdomen / pelvis showed no bowel obstruction or perforation. There was mild central biliary ductal dilation with common bile duct (CBD) measuring up to 9 millimeters. In the emergency room (ED), the patient was treated with intravenous fluids 1000 milliliters, intravenous morphine 4 milligrams, intravenous Rocephin, intravenous Toradol, and oral Carafate. The patient received intravenous Zosyn and intravenous fluids. Magnetic resonance cholangiopancreatogram (MRCP) was ordered. The patient was discharged on day #3. 

The Inpatient admission was not medically necessary. 

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding or evaluation requiring the patient to not eat or drink for an extended period (e.g., more than 24 hours). The patient did not have the inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists after observation care, and the patient did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on an ambulatory basis. Therefore, the inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (BVN) Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation (BVN) Procedure.
The determination is upheld.

This is a male patient with a chronic history of low back pain. Prior treatments have included chiropractic care, low back injections, and medications, as well as home exercises. The pain can be as high as 4 out of 10 and severely impacts her activities of daily living. Magnetic resonance imaging (MRI) of the lumbar spine reported Modic changes at disc spaces lumbar (L) 4-5. At issue is whether Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (BVN) Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation (BVN) Procedure.
The determination is upheld.

This is a male patient diagnosed with low back pain. Records indicate that the patient was recommended to undergo the Intracept procedure.
It was noted that the patient has chronic low back pain that began over six months ago. The patient has seen chiropractor, pain management and physical therapy. He has tried chiropractic treatment, home exercises, lumbar epidural injections, medial branch blocks, medication management, physical therapy, radiofrequency ablations, transforaminal epidural steroid injections. Medications have included over-the-counter medication. The pain is impacting activities of daily living and is rated at 4/10. The provider noted the patient had a magnetic resonance imaging (MRI) scan demonstrating motor changes at lumbar (L) 4 and L5 vertebral bodies and the provider believes that this is the source of the patient's chronic back pain.
The patient was seen with complaints of chronic low back pain described as burning, rated at 4/10 with constant, burning, shooting pain. The patient has temporary relief of chiropractic treatment and had epidural injections many years ago with some relief. The physical examination revealed tenderness to palpation at the lumber spine with palpable trigger points and limited lumbar range of motion. It was recommended the patient undergo the Intracept procedure. At issue is whether Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
No, the proposed health service or treatment Intraosseous Basivertebral Nerve Ablation (BVN) Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, the MRI provided did not show any Modic changes or degenerative endplate changes according to the radiologist read. There is a lack of high-quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.  This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower extremity pain and swelling
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a history of left lower extremity (LLE) deep vein thrombosis (DVT), who presented to the emergency department (ED) for left groin discomfort. The patient had a previous procedure intervention for DVT in another country. The review of systems was negative for additional symptoms. The patient was afebrile. 
The patient was admitted for a left lower extremity (LLE) venogram with stenting and thrombectomy. The patient was found to have a chronically occluded left common iliac vein and common femoral stent. The patient underwent left iliac vein recanalization. The postoperative course was uneventful and the patient was treated with Lovenox. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was not medically necessary.
The inpatient admission was not medically necessary at the inpatient level of care. The care could not have been safely rendered as an outpatient/elective procedure. Inpatient level of care is not justified.
The patient did not meet criteria for inpatient admission. She has no clear risk factors for bleeding complications, no evidence of limb-threatening thrombosis, no contraindication for anticoagulation or coagulopathy [1].
Patients with hemodynamic stability, ambulatory, low risk for bleeding, no evidence of renal failure, and is able to follow up can be safely and appropriately be scheduled for outpatient follow up [2]. Identifying patients at risk for morbidity and mortality, risk stratification of pulmonary embolism (PE) is paramount for tailoring their management and disposition [3]. The association of between DVT and PE can represent high risk patients with evidence of concomitant PE [3]. In this particular case, patient did not have shortness of breath or evidence of decrease in oxygen saturations. Additionally, the patient did not meet exception criteria for an ambulatory procedure. The patient was hemodynamically stable with no evidence of severe infection or ischemia. The patient is also young without comorbid conditions that would place her at risk for treatment failure or increase risk for complications and adverse events.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: right lower extremity pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

 
The patient is an adult male who has chronic bilateral lower extremity wounds and Kaposi Sarcoma. The patient was admitted for worsening right lower extremity pain (RLE) pain, drainage and foul odor, after discontinuing his oral opioid. The patient was treated with intravenous (IV) Dilaudid and then resumed his oral opioid. IV Dilaudid was administered for three days and the patient was discharged three days later to a lower level of care for wound care. 

The inpatient hospital admission was only considered medically necessary until intravenous (IV), as needed (PRN) Dilaudid was no longer needed, and it was reported that the patient had already re-started oral opioids for pain management. 

As such, the request should be partially approved. 

Per Jafari, S., et al., (2015), "Patients who are admitted to hospital because of deep tissue infections undergo a course of intravenous (IV) antibiotic therapy until the infection is resolved. Length of treatment varies from a couple of weeks to several months depending on the infection site and severity. After the patients are stabilized within the first days to a week after admission, they often are kept in hospital mainly because of lack of other alternatives in the community to complete the course of IV antibiotic. This results in unnecessary and lengthy hospital stay."

Per Abi-Aad, K. R., & Derian, A. (2023), "Close monitoring of patients for respiratory depression is imperative, especially during the initial 24 to 72 hours of commencing the therapy and subsequent dosage adjustments with hydromorphone. The hydromorphone dosage should be modified accordingly based on the monitoring results. Patients should be regularly assessed for adequate pain relief, blood pressure, mental and respiratory conditions, bowel functionality, indications of hypogonadism or hypoadrenalism, and signs and symptoms of misuse, abuse, and addiction."                                                         

Based on the above, the insurer's denial must be modified. 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 inpatient hospital admission is modified to reverse denial for the first three hospital days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She was hospitalized for CHF (congestive heart failure). She presented to the ED (emergency department) for evaluation of shortness of breath and constant left-sided chest pain with radiation to the left upper back. Her PMH (past medical history) is remarkable for hypertension, asthma, diabetes, NASH (nonalcoholic steatohepatitis), cirrhosis complicated by portal hypertension with esophageal varices and post TIPS (transjugular intrahepatic portosystemic shunt) procedure and currently on liver transplant list. The patient's vitals revealed blood pressure 125/67, heart rate 116, respiratory rate 22 and O2 (oxygen) saturation 96% on room air. EKG (electrocardiogram) showed sinus tachycardia. Chest film reported pulmonary vascular congestion. Chest CTA (Computed Tomographic Angiography) was negative for PE (pulmonary embolism). Treatment included IV (intravenous) steroids nebulizer, furosemide, antibiotic and aspirin. Echocardiogram was remarkable for grade 2 diastolic dysfunction and moderate severity aortic stenosis. The patient remained hemodynamically stable with gradual clinical improvement and was deemed stable for discharge. The requested coverage for Inpatient Hospital Admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, including the provided MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay were not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospitalization. The care that the patient received for mildly decompensated chronic LV (left ventricle) diastolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent drainage from the fistula tract
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with a history of a posterior transsphincteric fistula-in-ano. She notes persistent drainage from the fistula tract. A seton had been placed at her previous 
surgery. No significant comorbidities are documented on the pre-procedural history and physical. She was taken to surgery where she underwent a flap closure of her anal fistula. Following surgery, the patient was admitted to the hospital, as she was noted to be tachycardic with a heart rate of 120 decreasing to 100. This was felt to be secondary to pain as both electrocardiogram (EKG) and blood work were within normal limits. Her pain was managed with oxycodone 10 milligrams every four hours with Dilaudid as needed for breakthrough pain.
The following day the patient's pain was well controlled, and she was ambulating, tolerating diet, and voiding. She was discharged home the next day. The health plan has denied coverage of the inpatient stay as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

A review of the medical records submitted indicates that the patient was to be discharged home the same day as stated in the Procedure Report. The surgical post-operative check note documents the patient was in no acute distress (NAD) with pain rated 6/10. She was tolerating by mouth (PO) well and has a pulse of 99. The peri-operative nursing note signed on the day of admission post-surgical documents, "Patient states she is staying overnight." The surgical progress note dated the next day notes that the patient was in no acute distress with stable vital signs. The interval tachycardia had resolved and was attributed to pain. She was tolerating a regular diet and discharged home that day. Procedural guidelines consider anorectal surgery to be an ambulatory procedure that does not require admission to acute inpatient care unless exception criteria are met. The medical records do not support any untoward events during surgery or in the post-operative period that would warrant admission, nor did the patient have any documented comorbidities that would necessitate inpatient care. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective reversal of an ileostomy
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He presented to the hospital for elective reversal of an ileostomy. He was approximately one year status-post an abdominal colectomy with creation of J-pouch and covering loop ileostomy for fulminating Clostridium difficile colitis. On the day of admission, he was taken to surgery where under general anesthesia, he underwent a sigmoidoscopy and take down and closure of his loop ileostomy. The surgery was tolerated well and without immediate complications. The Surgical Progress Note of later that same day documents that the patient's vital signs were stable, and pain was well controlled. The patient was eating and drinking without issue, and passing low volume urine. CBC (complete blood count) was WNL (within normal limits, and potassium was elevated at 5.6. The Surgical Progress Note of post-operative day #1 documents the patient as afebrile with stable vital signs and resting comfortably in bed. The abdomen was tender but otherwise benign. The patient was tolerating diet, flatus is negative, and he did require straight catheterization once during the night. The morning labs were stable with potassium now WNL (within normal limits). His diet was advanced, ambulation encouraged, and analgesics converted to oral medication. The patient was discharged home on post-operative day #2 to be followed in the clinic.

The Inpatient admission was not medically necessary.

A careful review of the medical records submitted confirm that the patient experienced an uncomplicated surgery and had met discharge criteria by post-operative day #1 and could have been appropriately discharged at that time. He failed to meet any of the Exception Criteria as defined in the MCG (Milliman Care Guidelines). The intensity of service does not rise to the level to validate an acute inpatient setting and is appropriate for an ambulatory procedure with an overnight hold.