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

Diagnosis: Sickle cell crisis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a female patient with sickle cell disease who presented to the emergency room with abdominal pain that had been present for the 2 weeks prior to admission. She also had pain in her back and shoulders. Her pain was rated as 10/10. Her vital signs and laboratory studies were unremarkable. She had generalized abdominal pain on examination. Imaging was remarkable only for a right ovarian corpus luteum cyst. The patient was admitted for a sickle cell crisis. She was given intravenous (IV) fluids, analgesics (ketorolac and Tylenol), incentive spirometry, and daily labs.
While hospitalized, the patient was tachycardic and was evaluated for a pulmonary embolism (negative). She had a negative infectious disease evaluation. Laboratory studies remained stable without the need for transfusion. Her pain declined to 4/10 and the patient was discharged; inpatient care is under review for medical necessity.
The inpatient hospital admission was not medically necessary for this patient.
In Lanzkron, et al's study from 2021 that compared pain management in 483 adults with sickle cell disease (SCD) who were treated in an infusion center versus the emergency department (ED), better outcomes with infusion center treatment (faster administration of pain medication, greater likelihood of rapid reassessment, lower likelihood of hospitalization) was found with ambulatory management. This has been echoed by numerous other trials. This patient was hemodynamically stable, required minimal analgesics, and received almost entirely supportive care. Amongst other morbidities, she had no indications for emergent surgery, significant electrolyte abnormalities, evidence of acute chest syndrome, need for exchange transfusion, or evidence of an active infection. Supportive care does not require the inpatient setting. Support for inpatient care in this clinical scenario is not present in the medical literature nor in national guidelines. For these reasons, medical necessity for this admission cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rule out cracked tooth syndrome

Treatment: crown placement (D2470) on teeth numbers 8 and 9

The insurer denied coverage for crown placement (D2470) on teeth numbers 8 and 9

The denial is upheld

 
Upon review of the documentation provided which includes copy of periapical radiograph, multiple intraoral clinical photographic images, narrative letter from the patient, dental treatment record and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crowns for #8 and 9 due to tooth fracture and pain. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service and therefore the service does not meet medical necessity criteria.  The patient is appealing.

The objective documentation provided for review is a copy of periapical radiograph and intraoral clinical photos. There does not appear to be any radiographic evidence of caries nor is there evidence of significant coronal loss of tooth structure.  The radiographs do not substantiate the requested dental services as enumerated above.  While the clinical photographs indicate some incisal wear there is no evidence of cracked tooth syndrome and therefore the crowns are also deemed not medically necessary.

Uphold denial of coverage for crown placement (D2470) on teeth numbers 8 and 9 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

Crown placement (D2470) on teeth numbers 8 and 9 is not considered medically necessary for this patient.

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 crown placement (D2470) on teeth numbers 8 and 9 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower leg abscess

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Patient is an adult male with past medical history significant for polysubstance abuse who presented to the emergency department with complaints of left lower leg pain and swelling due to abscess.

Vitals on presentation included: Temperature 97.2 degrees F, Blood Pressure 140/87, Pulse 95, Respiratory Rate 18, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell count (WBC) 12.2, hemoglobin (HGB)-13.7, hematocrit (HCT)-41.3, creatinine-0.86, glucose-84, lactate-1.8.

Patient was started empirically on intravenous antibiotics (vancomycin) for left lower extremity cellulitis/ulcer. X-ray of tibia/fibula showed no evidence of trauma or osteomyelitis but did show soft tissue swelling and ulcer noted on anterior distal lower leg. He remained afebrile, hemodynamically stable, and clinically improved. Patient was discharged to continue oral antibiotics (Bactrim) as outpatient.

According to documentation, patient presented with left lower leg cellulitis. Otherwise, he was afebrile, hemodynamically stable, with unremarkable laboratory results except for a mildly elevated WBC. Patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management. 

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: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with no significant medical history who presented to the emergency room with abdominal pain. She was hemodynamically stable with evidence of tenderness in the abdomen on examination. Her white cell count was elevated and computed tomography (CT) scan of the abdomen and pelvis demonstrated acute appendicitis. The patient was taken to the operating room for laparoscopic appendectomy. Gangrenous 
appendix was found, without evidence of perforation, and she was admitted to the hospital. She was discharged the next day without evidence of infection. She was tolerating her diet, and her pain was well controlled. There was a denial for inpatient admission.

The requested health service is not medically necessary.

The medical records provided do not demonstrate medical necessity for inpatient admission for a diagnosis of acute appendicitis. After reviewing the medical records, this patient had gangrenous appendicitis without evidence of abscess or perforation. The patient was treated rapidly with a laparoscopic appendectomy. There was no evidence of acute sepsis on admission. The white cell count was 13, and her vital signs were otherwise hemodynamically stable. There is no documentation to support inpatient admission given that she tolerated her diet, her pain was well controlled, and she was discharged the next day. Since there is no documentation that supports inpatient admission, this is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia. 
Treatment: Inpatient hospital stay. 
The insurer denied the inpatient hospital stay.
The denial is upheld.

This patient is an adult male who came to the emergency department (ED) with shortness of breath (SOB) and wheezing for a week. He did not improve with oral antibiotics. Prior to arrival, the patient was given two DuoNeb treatments by emergency medical services, and they reported the patient's room air pulse oximetry (SpO2) was 95 percent (%). His past medical history consists of hypertension and diabetes. He is a former smoker. The patient's initial vital signs in the emergency department were heart rate 112, respiratory rate 20, temperature 98.5, blood pressure 112/80 (112 over 80), and room air pulse oximetry 98%. Physical examination was remarkable for wheezing. The patient did not appear in distress. His labs showed white blood cell count 10.2; hematocrit 45.8; glucose 129; sodium 141; and blood urea nitrogen (BUN) and creatinine 18/0.6. Chest x-ray reported a left lower lobe airspace consolidation that may be atelectasis. The patient was given Zithromax 500 milligrams (mg). He was also given intravenous Decadron for possible asthma exacerbation. He was admitted for severe sepsis from community acquired pneumonia and asthma exacerbation. He started on intravenous ceftriaxone, intravenous doxycycline, Duonebs, and Pulmicort. In addition, the patient was started on intravenous Decadron 10 milligrams (mg) every 12 hours. The patient was discharged on day number 4 (#4).

The requested health service was not medically necessary.

The patient presented to the emergency department with shortness of breath and wheezing. He had a temperature of 98.5. He was not hypoxic and was not hemodynamically unstable. He did not require high oxygen, positive airway pressure (PAP), or ventilator. The patient's chest x-ray reported airspace opacity in the left lower lobe or community acquired pneumonia. The patient did not require respiratory isolation. He did not require any surgical intervention while in hospital. The patient's wheezing and peak flow improved with steroids. According to Fine (4), the patient's pneumonia severity index (PSI) score was 49 points (based on age, vital signs, labs, no history of congestive heart failure, stroke, renal disease, clear mentation); this is low risk where outpatient management is recommended. The patient's 
confusion, urea, respiratory rate and blood pressure (CURB) 65 score was point 1 (based on no confusion, age, normal blood urea nitrogen [BUN] and respiratory rate [RR] 30); this is low risk where outpatient treatment is recommended. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess Skin
Treatment: Panniculectomy, excision of excessive skin & subcutaneous tissue, and suction assisted lipectomy
The insurer denied panniculectomy, excision of excessive skin & subcutaneous tissue, and suction assisted lipectomy.
The determination is upheld.

This is a female patient who lost 115 pounds over the past eight years. Her weight has been stable for five years. She complains of back pain. She has skin rashes under her pannus. Her surgeon recommends abdominoplasty, panniculectomy and liposuction. The plastic surgeon's office note indicates that the patient denies rashes. At issue is the medical necessity of panniculectomy, excision of excessive skin & subcutaneous tissue, and suction assisted lipectomy.

The requested procedures are not medically necessary. The patient has generalized skin laxity consistent with the history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) are health threatening or cause significant disability and 3) have failed to improve despite reasonable attempts at conservative therapy. A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include convincing and confirmatory evidence of a chronic problem that has failed reasonable attempts at conservative therapy. These proposed procedures do not meet this standard. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin fold, and photographs documenting cellulitis, ulcerations or rashes are not submitted. In addition, the medical records do not provide any documentation in the form of primary care physician (or provider) (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy given or 2) despite initial response, have recurred and caused significant f impairment. According to the letter from the plastic surgeon, the patient has rashes but the plastic surgeon's office note indicates that the patient denies rashes. The patient does not have a pannus fold and therefore, would be unlikely to have rashes. She reportedly has back pain but the records do not document any workup or conservative treatment for back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: Electrical Nerve Stimulation System (64590x1, 64555 x2)
The insurer denied: Electrical Nerve Stimulation System (64590x1, 64555 x2)
The denial is upheld.

The patient is an adult male with chronic back pain for whom implantation of a peripheral nerve stimulator (PNS) has been recommended. Specifically, the request is for Reactiv8, which is a multifidus muscle stimulator. He has failed PT (physical therapy), home exercise, medications, and injections. PE (physical exam) shows multifidus muscle instability. The request was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested Electrical Nerve Stimulation System.

The patient is an adult male with chronic back pain for whom implantation of a peripheral nerve stimulator (PNS) has been recommended. Specifically, the request is for Reactiv8, which is a multifidus muscle stimulator. He has failed PT (physical therapy), home exercise, medications, and injections. PE (physical exam) shows multifidus muscle instability. The requested procedure is not a commonly accepted treatment for this condition and is not effective in the treatment of chronic low back pain as shown by high-quality randomized control trials (RCT). There is a randomized controlled trial in the setting of chronic pain following amputation, but not this condition. These pathologies are quite different. Other case reports and observational studies show some benefits in other pain conditions. Other more proven, conventional treatments are superior in the literature, such as spinal cord stimulation. Some recent data has shown it may be effective as an add-on therapy to spinal cord stimulation (SCS), but not as a standalone therapy. Given the lack of data to support an invasive procedure for this type of condition, the requested Electrical Nerve Stimulation System is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: Electrical Nerve Stimulation System (64590x1, 64555 x2)
The insurer denied: Electrical Nerve Stimulation System (64590x1, 64555 x2)
The denial is upheld.

The patient is an adult male. Per the appeals letter, the patient has a history of chronic back pain, and a procedure known as Reactive8 is being requested. The patient has had chronic back pain for four to six years with worsening symptoms radiating down the right and left leg. The patient has tried epidural steroid injections. The patient has had neck pain for 20+ years radiating down to both forearms aggravated with activity. The requested service was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested Electrical Nerve Stimulation System.

Based on the documentation provided, the requested procedure is still considered investigational. Although the patient has a history of chronic low back pain and has tried prior treatment including medication, activity on moderate occasions as well and therapy, there is a lack of sufficient studies to support efficacy and safety. Until there is further evidence supportive of the procedure, it is not recommended in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: Electrical Nerve Stimulation System (64590x1, 64555 x2)
The insurer denied: Electrical Nerve Stimulation System (64590x1, 64555 x2)
The denial is upheld.

The patient is an adult male with low back pain for the past four to five years radiating down the right, greater than left, leg. Past treatments include medial branch block, radiofrequency ablation, epidural steroid injection, Via Disc, NSAIDs (nonsteroidal anti-inflammatory drugs), physical therapy, chiropractor, analgesia pain medications, muscle relaxants, and neuroleptic medications. MRI (magnetic resonance imaging) of the lumbar spine shows resolution of previously seen right paracentral disc herniation and 
discogenic degenerative endplate changes at L5-S1. The request for a ReActiv8 Implantable Neurostimulation System for low back pain stimulation of multifidus muscles was denied coverage by the health plan as experimental/investigational. the denial is being appealed.

The health plan should not cover the requested Electrical Nerve Stimulation System.

Some studies demonstrate the potential benefit of peripheral nerve stimulation in the treatment of low back pain. However, there is insufficient or inconclusive evidence published in peer-reviewed medical literature to evaluate the therapeutic value. There are no well-designed and well-conducted studies. There is inconclusive evidence published in peer-reviewed medical literature that the service improves net health outcomes. The service under consideration is not as beneficial as any established alternatives. Small, published case studies do demonstrate the significance of peripheral stimulation as an innovative approach to treating chronic pain, however, more studies are needed to substantiate its effectiveness and safety. As such the requested service is unproven or experimental/investigational (E/I).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Aide (PCA): Split Shift, 24 Hours per Day, 7 Days per Week 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for dementia and incontinence. 

The requested Personal Care Aide (PCA): Split Shift, 24 Hours per Day, 7 Days per Week is medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the question at hand is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
The patient has severe dementia and incontinence. She is not able to direct her own care. The notes describe that she requires frequent management of incontinence care and toileting overnight. Without continuous care, the patient would be left in soiled diapers for extended periods of time. This could lead to skin breakdown and/or infection. The patient recently had a urinary tract infection, and to reduce the risk of recurrence which would result in hospitalization, additional personal care support will be required. Therefore, the requested increase to continuous split shift 24-hour care is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Increase Personal Care Services To 7 Days A Week, Live in.
The insurer denied: Increase Personal Care Services To 7 Days A Week, Live in.
The denial is upheld.

The patient is an elderly female. Her medical conditions include dementia, osteoarthritis, atrial fibrillation, and diabetes. She has a history of falls one week prior to Uniform Assessment System evaluation. Denial of increase personal care services to 7 days a week, live in, is being appealed. The health plan approved 7 days per week, 8 hours per day. Her daughter is involved in her care and acts as backup caregiver. The patient's Uniform Assessment System (UAS) evaluation completed approximately 1 month ago shows moderately impaired cognition and functional status extensive assistance to total dependence with all ADLs (activities of daily living), except limited assistance with bed mobility and eating. She has bowel and bladder incontinence. She has a history of falls one week prior to UAS (Uniform Assessment System) evaluation. There is a decline in functioning compared to UAS (Uniform Assessment System) evaluation completed 5 months ago. The appeal reports that the patient has multiple comorbidities and is at risk of falling. She needs help with all ADLs (activities of daily living) and supervision, because she is at risk for falls. Her behavior is detrimental to her neighbors.

The requested Increase Personal Care Services To 7 Days A Week, Live in 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 Services to 7 days a week, live in, is being appealed. The health plan approved 7 days per week, 8 hours per day. The health plan denied an increase in hours because it is not indicated for safety supervision. This patient has multiple conditions, including dementia. Uniform Assessment System (UAS) evaluation completed approximately 1 month ago shows she requires extensive assistance to total dependence with all ADLs (activities of daily living), except limited assistance with bed mobility and eating. She has bowel and bladder incontinence. She has a history of multiple falls. The appeal statement supports that the patient requires assistance with all ADLs (activities of daily living) and is a fall risk. The appeal statement indicates live in personal care services are needed for supervision due risk for falls and dangerous behavior. The information provided does not support that the patient has functional needs requiring live in personal care services. Personal care services are not indicated for safety supervision or when no tasks are being performed. The requested increase personal care services to 7 days a week, live in, is not indicated to provide supervision. The currently approved services at 7 days per week, 8 hours per day are indicated.