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

Diagnosis: Uncontrolled type 2 diabetes

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

According to the records the patient has a diagnosis of uncontrolled type 2 diabetes. According to the records, she presented to the hospital for evaluation for right ankle pain. She had not taken her insulin for two days. She had a right tibial fracture and was not compliant with her orthopedic follow up.  Based on the Emergency Room (ER) records her glucose was over 500. Labs showed the following on a complete metabolic panel (CMP): glucose 533; bicarbonate 29; anion gap 10. Blood gas showed potential hydrogen (pH) 7.44.

Documentation provided for review did not support the inpatient admission.      

She does not meet  the Milliman Care Guidelines (MCG), inpatient admission criteria for uncontrolled diabetes.

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: Scrotal hidradenitis suppurativa
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male. He has a completely buried penis due to scrotal hidradenitis suppurativa. This condition has severely affected his quality of life due to pain, infection and embarrassment. He was treated with a wide, complex excision of the scrotum with a complex closure. He received 1 unit of PRBC (packed red blood cells) transfusion. The plan was for overnight observation.
On Post operative day #1, the patient was afebrile. The WBC (white blood cell) count was 24,400. IV (intravenous) antibiotics were administered. The patient had a Foley catheter and JP (Jackson Pratt) drain. He required IV (intravenous) pain meds and had difficulty with ambulation.
On the next day, the patient was discharged home.

The Inpatient Hospital Admission was not medically necessary.

The initial plan post-operatively was for a lower level of care. Although the patient required IV (intravenous) pain medications and had limited mobility due to pain, the management could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, dysuria
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with no medical history who presented to the hospital with abdominal pain, dysuria and nausea with chills for two weeks. She was noted to have an 
elevated white blood cell (WBC) count and was started on antibiotics and an antifungal. The inpatient level of care was denied. The physician is appealing the determination.

The proposed treatment was not medically necessary.

There is no documentation regarding hemodynamic instability, vomiting that was severe or persistent, or altered mental status that was severe or persistent. There was not persistence or 
worsening of clinical findings that could not have been managed at a lower level of care. The requested service is not medically necessary as it is for the convenience of the patient or the practitioner and not in the most appropriate setting.
Appeal type: Experimental/Investigational
Decision: Upheld



Diagnosis: Low back pain

Treatment: Intracept procedure

The insurer denied coverage for Intracept procedure

The denial is upheld

This patient has chronic low back pain. Her medication trials include Advil and Tylenol. She has had a Home Exercise Program and massage therapy. She has had Trigger Point injections as well as Medial branch blocks with radiofrequency ablation (RFA) subsequently.  On her magnetic resonance imaging (MRI) Modic changes are seen at lumbar (L)4, L5 and sacral (S)1.  The request is for RFA of the Basivertebral nerves (BVN) at L4, L5 and S1.	

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 (3) 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 basivertebral nerve (BVN). Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) 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

Urits et al (5) also commented on the need for more research on this promising technique:  "reproducible large RCTs are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RFA in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

This procedure is NOT likely to be more beneficial than the standard of care.

In summary, the denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral 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

Cardiac/Circulatory
Durable Medical Equipment

Diagnosis: Heart Failure
Treatment:
The insurer denied the LifeVest
The determination is overturned.

This is a male patient with a history of hypertension (HTN), hyperlipidemia (HL), diabetes mellitus (DM), chronic kidney disease (CKD) and heart failure with reduced ejection fraction (HFrEF) of 30 percent (%). He was hospitalized for decompensated heart failure and presented for outpatient cardiology follow-up. Per the office note, a LifeVest had been in place for a diagnosis of new onset nonischemic cardiomyopathy. Medications included Lasix, hydralazine and metoprolol. A LifeVest was ordered for two months. At issue is the medical necessity of the LifeVest.
The LifeVest is medically indicated/necessary in this case. It is being used for a patient who has increased risk for sudden cardiac death due to reduced left ventricular systolic function, as a bridge to implantable cardioverter defibrillator (ICD) implant or recovery of ventricular function. It is indicated as per the health plan policy. Per the health plan policy, the wearable cardioverter defibrillator may be considered medically necessary for patients with "newly diagnosed nonischemic cardiomyopathy that is potentially reversible after treatment with standard medical therapy has been initiated." That is the situation for this patient who is reported to have a new onset nonischemic cardiomyopathy with recent hospitalization during his office visit.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Muscoloskeletal/knee problem/pain/other/knee fracture
Inpatient hospital/inpatient admission
The health plan denied the requested inpatient admission as not medically necessary. The health plan's determination is upheld.

This is a female diagnosed with a left patella fracture. There is a request regarding inpatient care. An emergency department note documents that the patient presented with left knee pain after a fall. She reported ecchymosis and swelling in an inability to extend the knee. She was noted to have stable vital signs. An exam of the right knee documented reduced motion due to pain with tenderness and ecchymosis over the patella. There is also ecchymosis of the left patella. X-rays of the left knee documented a patella fracture. An electrocardiogram (EKG) was equivocal. The provider recommended a knee immobilizer and weight-bearing as tolerated after discussing care with orthopedics. Orthopedics recommended discharge home with follow-up as an outpatient. The provider stated that the patient and her family members felt it is unsafe for the patient to go home and therefore, they recommended admission for pain management. An admitting history and physical documents that the patient fell, with a complaint of left knee pain and reduced motion. The patient has comorbid hyperlipidemia. The patient felt it was unsafe to go home and therefore, she was admitted to the hospital. On the physical exam, she had an immobilizer over the left knee, and it was noted that there was mild swelling and ecchymosis of the left patella, as well as mild tenderness. Laboratory work was equivocal. An x-ray documented a left patella fracture. Orthopedics recommended outpatient follow-up. The provider recommended physical therapy and continuing Atorvastatin. A discharge summary documents that the patient was admitted with a patella fracture as it was felt that she was unsafe to go home. Physical therapy was consulted and recommended home physical therapy. The patient was discharged home with a plan for home physical therapy.

At issue is the medical necessity for the requested health service/treatment of an inpatient admission.

I recommend upholding the health plan's determination, in whole.

No, an inpatient admission was not medically necessary.

The patient presented with a complaint of left knee pain to the emergency department and was found to have a left patella fracture. Orthopedics recommended a knee immobilizer and outpatient follow-up with no plan for surgical intervention. The patient has no significant comorbidities. The patient felt unsafe to go home and therefore she was admitted, participated in physical therapy, and was discharged home with home health therapy. There is no documentation that the patient had a need for skilled care at an inpatient level. The patient was recommended outpatient treatment for the documented fracture. She had no significant comorbid conditions that required inpatient care. There is no documentation that indicated that the patient's care could not have been managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated troponin. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

This is a male patient who was admitted to the hospital with an elevated troponin. He has a history of hypertension and gastroesophageal reflux disease (GERD). On presentation, the patient had nausea and vomiting. He does use cannabis and it was thought to be due to this. The patient's white blood cell count (WBC) was 12 and the bilirubin was 1.3. Intravenous (IV) fluids were started and the nausea/vomiting improved in the emergency department (ED). The troponin was initially elevated slightly but did trend down. The patient was started on aspirin and Cardizem. He was advised to follow up with cardiology as an outpatient. The creatinine was essentially stable. At issue is the medical necessity of an inpatient stay. 
The patient did not meet medical necessity for the acute inpatient level of care per current literature and the standard of care for the duration of the hospital stay. A lower level of care would have been appropriate. 
The patient did not have acute coronary syndrome and the troponin did trend down. The nausea and vomiting also improved in the ED. There were no other severe or refractory findings or symptoms noted that would have necessitated inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is an adult with a history of osteoarthritis, nicotine abuse, obesity, and hypertension. The patient presented to the hospital for a scheduled left total knee replacement (TKR). The procedure was uneventful. There were some pains in the left lower extremity (LLE) after surgery. The patient reported to be in a lot of pain. The patient participated in physical therapy (PT) during the admission. The patient was discharged with instructions to follow up with the Orthopedist on an outpatient basis. 

The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient had surgery and care after surgery. The patient could have been safely treated at the observational level after knee replacement surgery. The requested service is denied based on Milliman Care Guidelines 26th Edition using the guideline of Musculoskeletal Surgery or Procedure and InterQual criteria for Inpatient Setting after Total Joint Replacement 2021: Comorbidity requiring inpatient setting. 

The medical records show ongoing pain which was not responsive to current regimen. The Visual Analog Scale (VAS) scores were 6 on constant basis. There was the need for intravenous (IV) narcotic. The physician record reports ongoing pain and the need for pain control. The physical therapy records show problems with mobilization. The pain levels continued to be elevated despite medications. The clinical record would thus support the need for additional service. 

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: Overturned

Diagnosis: thoracic endometriosis

Treatment: Orilissa 200 milligram (mg) OR tabs

The insurer denied coverage for Orilissa 200 milligram (mg) OR tabs

The denial is overturned

This is an adult with a history of thoracic endometriosis status post multiple thoracic procedures requesting coverage for Orilissa. The patient is maintained on Norethindrone acetate except that she is complaining of significant dyspareunia. 

Endometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces a range of clinical and radiological manifestations. This includes catamenial pneumothorax, hemothorax, hemoptysis, and pulmonary nodules, resulting in an entity known as thoracic endometriosis syndrome (TES). Thoracic endometriosis syndrome (TES) can produce incapacitating symptoms for some patients. Medical management represents the first-line treatment approach. When this fails or is contraindicated, definitive surgical treatment for cases of suspected thoracic endometriosis syndrome (TES) uses a combined video laparoscopy performed by a gynecologic surgeon and video-assisted thoracoscopic surgery performed by a thoracic surgeon. Postoperative hormonal suppression may further reduce disease recurrence.
This patient is maintained on Norethindrone but is complaining of significant dyspareunia.

According to the standard of care, and American Society for Reproductive Medicine (ASRM) recommendations, the treatment of endometriosis-related pain is based on the severity of symptoms. 

For women with severe symptoms, symptoms that do not respond to the above therapies, or recurrent symptoms, a trial of gonadotropin-releasing hormone (GnRH) agonist with add-back hormonal therapy or a GnRh antagonist is recommended (Grade 2C). 

Orilissa is a Gonadotropin-hormone releasing (GnRH) antagonist which suppresses pituitary gonadotropin hormone production and creates a hypoestrogenic state and is approved as a treatment for endometriosis for the management of moderate to severe pain associated with endometriosis. 

Based on the above, the insurer's denial must be overturned. 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 Orilissa 200 milligram (mg) OR tabs services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a teenage male with review for inpatient hospital admission. The patient has a history of sickle cell disease, polycystic kidney disease, single kidney, and asthma. He presented to the emergency department with complaints of left shoulder and right hip pain. He was hemodynamically stable and afebrile. Laboratory studies demonstrated a white blood cell count of 12.5, hemoglobin 6.8 and platelet count 446 thousand (K). The patient had an appropriate reticulocytosis. The patient was hyponatremic with a sodium 130 and he had a bilirubin of 4. X-ray of the hip demonstrated normal findings. The patient was admitted to the hospital for intravenous fluids and pain medication. The patient was transfused 1 unit of packed red blood cells. Orthopedics was consulted and recommended management for sickle cell vaso-occlusive crisis. The patient was discharged on day #3.

The proposed inpatient hospital admission was not medically necessary.

In this case, acute inpatient level care would not be considered medically necessary for this patient. The patient was admitted to the hospital with hip and shoulder pain. The patient was afebrile. The patient did not have any significant sickle cell complications such as acute chest syndrome, stroke, aplastic crisis, duration or intractable pain beyond observation level of care, splenic sequestration, fever or bacteremia. The patient had a normal pulse oximetry and did not require any oxygen supplementation. The patient was given 1 transfusion. As such, in this case acute inpatient level care would not be considered medically necessary. Ambulatory/observation level care is more appropriate in the setting given the patient's symptoms resolved within time and there were no inpatient level of care needs as described above.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory
Home Health Services

Diagnosis: Coronary Artery Disease
Treatment: 40 hours hours/week, consumer direct, 1 client personal care aide
The insurer denied 40 hours hours/week, consumer direct, 1 client personal care aide. 
The determination is upheld.

This is a male patient with a medical history notable for coronary artery disease. The patient is approved for 21 hours per week of consumer directed personal care aide. The patient and his care team requested an increase to 40 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The patient has a medical history of coronary artery disease, diabetes, hypertension, hyperlipidemia, human immunodeficiency virus (HIV), and neuropathy. He uses a walker to ambulate. The patient needs assistance with multiple activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The physician feels that the patient's current allotment of home care hours is not sufficient to meet his needs. There were no details provided on currently unmet personal care needs.
Another physician provided a letter of support for this appeal. At that time, the patient was approved for 5 hours per week of home health care, and the physician requested an increase to due obesity and other health factors that lead the patient to get "tired and easily winded with daily activities."
A Uniform Assessment System (UAS) was completed and was available for review. The patient was cognitively intact with normal short term recall and procedural memory. He reported some subjective forgetfulness. For his IADLs, he requires extensive assistance for housework, finances, medications, stairs, shopping, and transportation. he is independent for meal preparation and phone use. He is independent for all ADLs. He ambulates independently with a walker. He is infrequently incontinent of urine and continent of stool. At issue is the medical necessity of 40 hours hours/week, consumer direct, 1 client personal care aide. 

The requested health service/treatment of 40 hours hours/week, consumer direct, 1 client personal care aide has not been demonstrated to be medically necessary for this patient.
The patient requires some assistance with most IADLs. He is independent for ADLs. His physician certified that 5 hours per week was not sufficient to meet his care needs, but he is now approved for 21 hours per week. It is not clearly demonstrated which personal care needs, if any, are not being met with his current allotment of personal care hours. Therefore, the requested increase of hours has not been demonstrated to be medically necessary for this patient.