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

Diagnosis: Upper and lower crowding
Treatment: D8080 - Braces
The insurer denied: D8080 - Braces
The denial is upheld.

The patient is a teenage male. The request is for orthodontic benefits. The patient has mild upper and moderate lower crowding. The prior denial was due to having a handicapping index score of 21.

The requested health service is not medically necessary.

The patient does not have any issues pertaining to chewing, speaking, or swallowing, regarding his teeth. It was originally stated that the patient has a Class III malocclusion. However, 
according to the photos, he does not have a Class III malocclusion, so it does not need to be treated. The orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Great Toe Infection 

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient has a past medical history significant for hyperlipidemia, diabetes mellitus, and coronary artery disease who presented to the emergency department with complaints of right great toe infection.

Vitals on presentation included: Temperature 98.0 Fahrenheit (F), blood pressure (BP) 148/79, pulse (P) 79, respiratory rate (RR) 18, oxygen (O2) saturation 98% on room air (RA). Laboratory results included the following: white blood cell count (WBC) 12.8, hemoglobin (HGB) 16.0, hematocrit (Hct) 49.8, creatinine 0.90, glucose 171, c-reactive protein (CRP) 11.84, and lactate 3.61.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for a  right foot infection. X-ray of the foot showed ulcer of the first digit with adjacent cortical irregularities suggestive of acute osteomyelitis of the first distal phalanx. Podiatry was consulted and recommended topical wound care including dressing changes. Infectious Diseases recommended continuation of antibiotics. The patient underwent a bone biopsy. A peripherally inserted central catheter (PICC) line was inserted for long-term intravenous antibiotics.

According to documentation, patient presented with osteomyelitis of right big toe. On presentation, the patient was hypertensive, laboratory results showed elevated WBC and inflammatory markers (erythrocyte sedimentation rate (ESR), CRP). Imaging studies were consistent with acute osteomyelitis.  

Based on the above, the insurer's denial must be reversed. 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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Latent Tuberculosis Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient presented to the hospital with a history of upper respiratory tract infection-like symptoms.  The patient reported some cough for about two months that had worsened in the past 15 days.  The patient reported being told that they had tuberculosis (TB) two months prior.  It appears that this was a latent tuberculosis infection.  Vital signs on presentation to the emergency department (ED) were: Temperature 98.5 Fahrenheit (F), Blood Pressure (BP) 116/78, Heart Rate (HR) 84, and Oxygen (O2) Saturation 97%.

The patient's physical exam was within normal limits.  The lungs were clear.  The patient's Chest X-ray (CXR) showed no acute infiltrates.  The patient was admitted and kept in isolation.  A sputum for acid fast bacilli (AFB) was sent.  The patient had a purified protein derivative (PPD) test placed.

This patient did not need acute inpatient hospitalization.  There was no indication that this patient had active TB.  The patient was afebrile and hemodynamically stable.  The patient remained stable after admission.  The patient was discharged with outpatient follow-up after two days.  The patient likely had a latent TB infection that could have been treated as an outpatient.  

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II canines
Treatment: Braces and Monthly Visit
The insurer denied: Braces and Monthly Visit
The denial is overturned.

The patient is an adolescent female requesting orthodontic benefits and monthly visits. She has Class II canines with moderate upper and lower crowding. The prior denial was due to a handicapping index score of 14 points.

The requested health service is medically necessary.

Teeth numbers 4 (upper right premolar) and 20 (lower left premolar) are not erupting in their normal positions. Their incorrect positioning will cause food traps to develop, with resulting caries (cavities). Orthodontic treatment is needed to correct these problems. The monthly visits are needed to make sure treatment is progressing properly. This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope with Hypotension. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is the case of a patient that presented to the hospital with syncope. The patient's past medical history was significant for syncope, implantable loop recorder, peripheral artery disease, atrial fibrillation, cerebrovascular accident (CVA), bipolar disorder, and chronic obstructive pulmonary disease (COPD). The patient lost consciousness while exercising. The patient was found to be somnolent by emergency medical services (EMS) and blood pressure (BP) at the time was 56/31. The patient was treated with one liter of fluid. Upon arrival to the hospital vital signs were stable (systolic blood pressure (SBP) 108, pulse 59). The patient was subsequently noted to have a BP of 95/54. 12 lead electrocardiogram (ECG) revealed sinus bradycardia without ischemic findings and QTc interval of 420. Physical exam revealed no abnormalities. Serum blood tests revealed a blood urea nitrogen (BUN)/creatinine (CR) ratio (12/0.9). The patient was admitted to the hospital for additional work up and treatment. A computed tomography (CT) scan of the head revealed no abnormality.  Echocardiogram demonstrated a preserved left ventricular ejection fraction (LVEF) of 63% without valvular abnormalities. Cardiac work up was unrevealing, and the patient was discharged home with a diagnosis of volume depletion versus vasodepressor syncope. 

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This patient presented with syncope during exercise and was noted to be hypotensive. Given the patient's history of syncope at the time of exertion and history of bipolar disease treated with multiple QT prolonging medications, cardiac syncope was a concern. The patient was treated with intravenous (IV) fluid and their blood pressure recovered. According to the European Society of Cardiology, patients presenting with syncope must be risk stratified for future morbidity and mortality in order to determine the need for hospital admission (1). In a study of individuals presenting to the emergency room, patients that were moderate or high risk for cardiac events had a poor prognosis and required admission to the hospital for additional testing and treatment (2).  In this case, the patient was hypotensive and remained with borderline blood pressure and bradycardia following IV fluid administration. Although the likely etiology of syncope was volume depletion careful observation and testing was indicated.  Admission to the hospital for treatment and risk stratification was medically necessary in this case in order to monitor blood pressure.

Based on the above, the insurer's denial must be reversed. 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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Volume Overload
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female for whom an inpatient hospitalization is under review. The patient has a history of end-stage renal disease on dialysis, hypertension, and supraventricular tachycardia (SVT). The patient presented with shortness of breath, chest pain, and orthopnea. She was volume overloaded. Electrolytes were essentially normal. Chest X-ray was suggestive of interstitial pulmonary edema. The electrocardiogram (ECG) was reported as non-acute. There was no workup of breathing or accessory muscle use. She was given some intravenous Lasix. A recent stress test was negative. An echocardiogram was reported as within normal limits. There was no urgent need for hemodialysis. She was hypertensive. Oxygen saturation was normal. She underwent hemodialysis on day #2. She remained stable and improved and was discharged.

The inpatient admission was not medically necessary.

This patient presented with volume overload in the setting of end-stage renal disease, as well as hypertension. These improved with medical therapy and hemodialysis. She remained stable and was an early responder to medical therapy. There was no hemodynamic instability, worsening cardiac symptoms, severe electrolyte abnormality, renal failure, need for ongoing oxygen support, severe arrhythmia, acute coronary syndrome, myocardial infarction, persistent medically refractory hypertension, need for ongoing in-hospital intravenous medications, need for mechanical or pharmacologic cardiac support, or administration of high-risk medications requiring in-hospital monitoring. As such, medical necessity for acute inpatient hospitalization was not met. In the setting of this case, an inpatient level hospitalization, compared to for example observation, has not been established standard of care toward improved cardiac outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Home health care

Diagnosis: dementia
Treatment: home health care
The insurer denied 24 Hours per Day (2 Shifts of 12 Hours of Aide Service), 7 Days per Week of Consumer Directed Personal Assistance Services in the Home 
The health plan's determination is upheld. 

The patient is a female with past medical history of dementia, diabetes mellitus (DM) type 2, diabetic retinopathy, hypertension, hyperlipidemia, and urinary incontinence who entered nursing home/rehabilitation facility. There was a plan for the patient to return to home and there was a request to have 24-hour Consumer Directed Personal Assistance Services (CDPAS). The patient underwent an assessment tool assessing the patient at total assistance with task of managing medication while maximum assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, shopping, and transportation. With tasks of personal hygiene and dressing upper and lower body, the patient was assessed at limited assistance while supervision with tasks of stairs, bathing, walking, locomotion, transfer toilet, toilet use, and eating. The patient was assessed and independent with task of bed mobility. 

24 Hours per Day (2 Shifts of 12 Hours of Aide Service), 7 Days per Week of Consumer Directed Personal Assistance Services in the Home are not medically necessary for this patient.
There is documentation from the universal assessment and the provider's own letter that the patient's care needs are specifically for safety and supervision. PCA (personal care aide) services are covered to assist the patient with activities of daily living (ADL) and Instrumental activities of daily living (IADL) and not for safety and supervision. There is no documentation from the patient's provider or family of assistance needs with ADLs or IADLs that will require 24-hour split shift services. There is no documentation of overnight care logs specifically documenting the patient's ADL assistance needs nor documentation of medical necessity of turning and repositioning every 2 hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder pain
Treatment: Shoulder surgery (29826-29828)
The insurer denied the shoulder surgery (29826-29828).
The denial is upheld.

This is an adult female patient with shoulder pain. She had fallen last year and reported a right shoulder injury. She had ongoing problems with activities of daily living. The physical examination was significant for physician reports "deferred". The magnetic resonance imaging (MRI) report was significant for partial high grade articular tear of the cuff, possible full tear. The physician recommended several arthroscopic procedures (rotator cuff repair, biceps tendonesis); they were performed 2 months later.

The requested health service was not medically necessary.

The services require a physical examination showing positive signs of weakness, loss of motion, and special tests. The physical examination in this case was "deferred". The magnetic resonance imaging (MRI) scan did not show a full tear but was reported as possible. The services require a course of conservative treatment. The records show no conservative treatment was provided. There was no documentation of physical therapy or medications. The criteria were not met. Prior to surgery, a course of conservative treatment should be provided. There should be a complete history and physical examination completed. This was not performed. The surgery was completed six weeks after initial consultation without additional information.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: procedure to treat low back pain (CPT codes 64628 and 64629)

The insurer denied coverage for procedure to treat low back pain (CPT codes 64628 and 64629).

The denial is upheld.

This woman has chronic low back pain.  She has done Physical therapy and Trigger Point injections. She has had sacroiliac (SI) joint injections and Epidural Steroid injections.  Her medication trials include: Tylenol, Flexeril, Gabapentin, Hydrocodone, Percocet, Tizanidine, and Tramadol. Her magnetic resonance imaging (MRI) shows Modic changes at lumbar (L)3, L4, L5 and sacral (S)1.  The request is for radiofrequency ablation (RFA) of the Basivertebral nerves (BVN) at L3, L4, L5 and S1. Her weight is noted as 325 pounds and she has a history of depression. The only clinical note dated five months ago does not contain a physical exam of the musculoskeletal or neurologic system. Review of the MRI report dated one year ago noted Modic type 1 changes from L2-L5. Also noted at L2-L3 is moderate spondylosis and left lateral recess stenosis encroaching on L3 nerve root. At L3-L4  moderate spondylosis and moderate foraminal stenosis. As per Khalil et al, this patient would have been excluded from their randomized study. 

The publications to date have been company sponsored and had methodology flaws.  There are no published data on long-term complication rates.  There are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al (4) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN (basivertebral nerve ablation). Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (5) while favorable pointed out the limitations of the current literature:

.  Industry funding is a potential source of study bias for the available data reviewed.
.  Limited number of studies.
.  Short-term follow up for the majority of studied patients.
.  Unknown effect on the primary degenerative process

In sum, this procedure is NOT likely to be more beneficial than the standard of care.

The denial of procedure to treat low back pain (CPT codes 64628 and 64629) and coverage for the requested service/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 risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: procedure to treat low back pain (CPT codes 64628 and 64629)

The insurer denied coverage for procedure to treat low back pain (CPT codes 64628 and 64629).

The denial is upheld.

In assessing whether intraosseous basivertebral nerve ablation using the Intracept device is considered more beneficial for this patient than standard treatments or procedures, it is important to know that the publications in peer-reviewed literature to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. Furthermore, despite Food and Drug Administration (FDA) approval, there are many exclusion criteria.

For individuals who have vertebrogenic low back pain who receive ablation of basivertebral nerves, the evidence includes two randomized controlled trials (RCTs) (SMART and INTRACEPT trials, both sponsored by device manufacturer Relievant Medsystems, Inc.). Relevant outcomes were symptoms, functional outcomes, quality of life and treatment-related morbidity. In one RCT, at 12 months, 73% (percent) of patients crossed over to the active treatment group and therefore long-term comparative data is not available. Limitations to the other RCT include lack of a sham control and short duration of follow-up. Furthermore, a 2021 systematic review (Conger et al.) concluded that further high-quality, large prospective studies, that are not industry funded, are needed to confirm these findings.

This patient is not a good candidate for intraosseous basivertebral nerve ablation. There are other evidence-based treatments available to this patient. 

This procedure is unlikely to be more beneficial than the standard approaches. 

There are other evidence-based medications and treatments available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments.

In summary, the denial of procedure to treat low back pain (CPT codes 64628 and 64629) and coverage for the requested service/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 risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia.
Treatment: Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is overturned.

This patient is an adult male with cough, chest congestion, and weakness. He presented to the emergency room for evaluation. The patient was found to have pneumonia and was started on intravenous antibiotics and intravenous fluids. The patient was admitted to acute hospitalization for the management of pneumonia. The patient remained in acute hospitalization due to worsening leukocytosis and hypotension. The admission from was denied due to lack of medical necessity. This denial is being appealed.

The requested health service was medically necessary.

The patient has severe sepsis due to pneumonia. The patient had hypotension and leukocytosis that persisted in the emergency room and during the hospitalization. The patient required frequent intravenous fluid resuscitation as well as frequent Tylenol for fevers and antibiotics. The patient's confusion, uremia, respiratory rate, BP (blood pressure), age greater than or equal to 65 years (CURB-65) score of two suggests the 30-day mortality rate is 6.8 percent. This also suggests inpatient treatment for pneumonia. The requested service was medically necessary. The intensity of treatment needed for the patient could not be safely and effectively delivered at a lower level of care other than acute hospital level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: General debility, right ankle fracture-dislocation
Treatment: Continued Skilled Nursing Facility
The insurer denied: Continued Skilled Nursing Facility
The denial is overturned.

The patient is an adult male with a history of general debility and ambulatory difficulty due to right ankle fracture-dislocation status post open reduction internal fixation (ORIF), right clavicle fracture, and right ulna shaft fracture. Relevant past medical history includes alcohol abuse, liver cirrhosis, hepatic encephalopathy, seizures, gastroesophageal reflux disease (GERD), esophageal varicose, gastric ulcer, hemorrhage, depression, and hypertension. The patient was admitted as non-weight-bearing (NWB) right lower extremity and right upper extremity. Ongoing medical issues include hepatic encephalopathy, gastroesophageal reflux disease (GERD), and hypertension. Prior to admission, the patient was living in a shelter and was independent. He was admitted to a skilled nursing facility (SNF) and was totally dependent for most activities of daily living. As of 4 months ago, the patient was non-ambulatory due to non-weight-bearing status; he required supervision with upper body dressing; he required maximum assistance with dynamic standing and transfers; he required moderate assistance with wheelchair mobility, bathing, and toileting; and he required minimum assistance with bed mobility, and lower body dressing.

The requested health service is medically necessary. 

The continued stay in the skilled nursing facility was medically necessary because of multiple medical issues including non-weight-bearing status. 

As of 4 months ago, the patient was non-ambulatory due to non-weight-bearing status. He required supervision with upper body dressing; maximum assistance with dynamic standing and transfers; moderate assistance with wheelchair mobility, bathing, and toileting; and minimum assistance with bed mobility, lower body dressing, etc. Continued stay in a skilled nursing facility was medically necessary. The stay should be approved until the patient's status had improved with him requiring set up for transfers, walking 175 feet with supervision, navigating 15 steps with supervision, and independent with bed mobility. The 3 months in skilled nursing facility is dependent on many factors and in this case, the patient was totally dependent when he was admitted with a lot of medical issues. He continued to show progress and by early last month, he was doing well, and it was no longer medically necessary for him to continue to be there.