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

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.



The patient is an adolescent female admitted for lower abdominal pain associated with nausea and vomiting. Examination showed guarding and rebound. Laboratory evaluation showed significant leukocytosis and elevated white blood cell (WBC) count. The patient was treated for pelvic inflammatory disease (PID) and was given intravenous (IV) Toradol, IV morphine, an IV fluid bolus, and IV Rocephin. 

Most women with pelvic inflammatory disease (PID) can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include:

	Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
	Complicated pelvic inflammatory disease with pelvic abscess (including tubo-ovarian abscess)
	Possible need for invasive diagnostic evaluation for alternate etiology (e.g., appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
	Inability to take oral medications due to nausea and vomiting
	Pregnancy 
	Lack of response or tolerance to oral medications
	Concern for nonadherence to therapy

This patient fulfills the above criteria for admission. She was in severe abdominal pain and was unable to take oral medications because of nausea and vomiting. Once, the patient was deemed stable with an improvement of her symptoms, and was able to tolerate oral intake, she was discharged home. 

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Swelling of Right Leg
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He presented with lower extremity swelling following knee ligament repair. He was seen postoperatively and was found to have venous thromboembolism (VTE). He was sent to the emergency room for management. A repeat ultrasound confirmed deep vein thrombosis (DVT). He was placed on Lovenox and admitted. He had no pulmonary 
embolism (PE). He was changed to Eliquis and discharged the following day.

The inpatient admission was not medically necessary.

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's 
illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (1)
"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (2) "In summary, hospital case managers are a crucial resource for making admission decisions. Hospitalists should be familiar with Medicare criteria for inpatient versus observation status. Patients who are likely to require 24 hours or less for a disposition decision should be assigned observation status. When in doubt, admit to observation since conversion to inpatient status is a simple process." (3) Multiple studies have shown that outpatient treatment of venous thromboembolism is safe and feasible. However, this individual with an elevated creatinine was not suitable for initial management of outpatient venous thromboembolism. He was otherwise stable with distal deep vein thrombosis and had been excluded for pulmonary embolism. He would have had an anticipated short need for hospital stay of 24 to 48 hours to initiate anticoagulation. As such, a lower level of care, as opposed to acute inpatient admission, would have been appropriate. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic knee pain

Treatment: Physical therapy (PT), 97110 x2 and 97112 x2

The insurer denied coverage for physical therapy (PT), 97110 x2 and 97112 x2

The denial is upheld 


This is an adult male with chronic knee pain. Treatment included physical therapy (PT). Under review is the medical necessity of continued PT, 97110 x2 and 97112 x2; 4/27/22, 5/7/22, 5/10/22, 5/17/22, 5/25/22, 6/1/22, 7/6/22, and 7/13/22. 

Based on the enclosed clinical information available for review, continued physical therapy (PT), 97110 x2 and 97112 x2 was not medically necessary. The letter from the patient's treating physician was reviewed; indicating "physical therapy services should be covered during 2022 and 2023." However, it does not include his associated treatment notes that should contain measurable objective findings and/or specific functional deficits amenable to physical therapy treatment. In addition, the physical therapy prescription was for back pain and not knee pain. 

The physical therapy treatment notes provide insufficient objective clinical evidence to support the medical necessity of the services provided. The clinical records do not demonstrate the medical necessity of continuing a structured out-patient physical therapy treatment program. The medical records do not demonstrate improvement can be expected within a reasonable time frame, services are needed to maintain, prevent, or slow a decline in condition, and the skill of a therapist is needed to manage, carry out, or set up a safe and effective treatment program. 

From a physical medicine and rehabilitation/pain management perspective continued physical therapy (PT), 97110 x2 and 97112 x2, was not medically necessary.

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 continued physical therapy (PT), 97110 x2 and 97112 x2 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy

Treatment: certified nurse midwife (CNM)

The insurer denied coverage for certified nurse midwife (CNM).

The denial is upheld.

The insurer has denied coverage for a certified nurse midwife (CNM). In their Final Adverse Determination letter, they write that the patient does not meet the criteria for a home birth as they have had a prior cesarean section. The insurer writes that the Committee on Obstetric Practice considers fetal malpresentation, multiple gestations, or prior cesarean delivery to be an absolute contraindication to a planned home birth, and the published peer-reviewed medical literature does not support the request.

The patient's spouse is appealing. In an appeal letter, they write that they chose to have a home birth due to the fast nature of their prior labors and the unassisted delivery of their previous baby in their driveway. They also did not want to expose their family and new baby to COVID-19. In an appeal letter, the patient writes that their first birth was a cesarean section but has since given birth vaginally to 3 more children without any medical interventions.

A recent U.S. study showed that planned home trial of labor after a (cesarean) c-section (TOLAC) was associated with an intrapartum fetal death rate of 2.9 in 1,000, which is higher than the reported rate of 0.13 in 1,000 for planned hospital TOLAC. This observation is of particular concern in light of the increasing number of home vaginal births after cesarean delivery. Because of the risks associated with TOLAC, and specifically considering that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with trained staff and the ability to begin an emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits with the provision of emergency care.

According to The American College of Obstetricians and Gynecologists (ACOG), the decision to offer and pursue TOLAC in a setting in which the option of immediate cesarean delivery is more limited should be considered carefully by patients and their healthcare providers. In such situations, the best alternative may be to refer patients to facilities with available resources. Healthcare providers and insurers should do all they can to facilitate transfer of care or co-management in support of a desired TOLAC, and such plans should be initiated early in the course of antenatal care.

Noting the fact that the patient had 3 vaginal deliveries after a first c-section does not decrease the risk but instead increases it as the fact that the patient is a multigravida may increase the risk of postpartum hemorrhage. 

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 a certified nurse midwife (CNM) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Covid-19.
Treatment: Inpatient admission.
The insurer denied coverage for Inpatient admission.
The denial is: Overturned.
The patient is an adult HIV/AIDS-infected patient not on highly active antiretroviral therapy (HAART), a cluster of differentiation 4 (CD4+) 133, with a past medical history significant for hypertension and unspecified psychosis who presented to the emergency department (ED) with complaints of fever, cough, and diarrhea. 

Vital signs on presentation included: Temperature 104.4 Fahrenheit, Blood Pressure 145/75, Pulse 121, Respiratory Rate 20, and oxygen (O2) saturation 93% on Room Air. Laboratory results included: White blood cell count (WBC) 11.77k, hemoglobin (Hgb) -13.4, hematocrit (Hct) -40.6, creatinine -1.5, C-reactive protein (CRP) 268, aspartate aminotransferase (AST) 101, COVID-19 positive. Chest radiographic image (CXR) showed retro-cardiac opacity with air bronchograms.

The patient was started empirically on COVID-19 treatment including Remdesivir and Dexamethasone. The patient was also treated with broad-spectrum antibiotics (Vancomycin/Zosyn/Azithromycin) completion of management. The patient improved clinically and remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management.

According to documentation, the patient presented with high fevers (104.4) and tachycardia (heart rate-121). Laboratory results showed multiple abnormalities including elevated WBC, CRP, AST) and COVID-19 positive. Based on the above findings in an immunocompromised patient with AIDS and concomitant COVID-19 infection, hospital admission was medically necessary.  

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: Right Shoulder Pain

Treatment: right shoulder magnetic resonance imaging (MRI)

The insurer denied coverage for right shoulder magnetic resonance imaging (MRI)

The denial is upheld 

This is a patient with right shoulder pain. The patient was evaluated by a rheumatologist. The patient reported good motion but tenderness to rotation. The patient was previously diagnosed with rotator cuff disease (Partial thickness tear as per magnetic resonance imaging (MRI)). An x-ray was unremarkable. An MRI was ordered. It showed a near full thickness tear with tendinosis. 

An MRI is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed.

The performance of the MRI should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary.

The medical records show a telemedicine consultation was completed. There was no hands on physical examination. There was no reported weakness nor loss of motion.  There were no treatments reported. There was no documentation to a course of physical therapy (PT), medication nor injection. There was no indication that surgery was considered. 

Based upon the lack of conservative treatment, the study would not have been necessary. 

There were no extenuating circumstances to substantiate necessity of MRI testing.

Official Disability Guidelines 2023: "MRI imaging studies are valuable when physiologic evidence indicates tissue insult or nerve impairment or potentially serious conditions are suspected like tumor, infection, and fracture or for clarification of anatomy prior to surgery."  In this case, none were noted.

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 right shoulder magnetic resonance imaging (MRI) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus
Treatment:  Mounjaro 15 milligrams (mg)/0.5 milliliter (ml)
The insurer denied  Mounjaro 15 milligrams (mg)/0.5 milliliter (ml).
The health plan's determination is upheld.

The patient is a male diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. As per the letter from the provider states he has been on under his care for almost 1 year for T2DM and Obesity; he is currently taking Mounjaro and he is achieving both well controlled diabetes and weight loss.

The requested health service/treatment of Mounjaro is not medically necessary for this patient. The requested medication Mounjaro (Tirzepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a  glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c (HgbA1c) as well as weight loss [1-3].
There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American diabetes Association guidelines recommend using GLP-1 receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists[4]. The patient can try two more formulary alternatives. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: lower back pain
Treatment: Outpatient Intracept Procedure
The insurer has denied the Outpatient Intracept Procedure. 
The health plan's determination is upheld.

The patient is a female with a history of chronic low back pain after a fall over 5 years ago. She was seen by Physical Medicine and Rehabilitation for a new pain clinic visit. Her pain was in the midline lumbosacral area and right paramidline with radiation to the bilateral gluteal regions and posterior thighs. It was worse with sitting and walking. She had transforaminal epidural steroid injections last year with 60-70 percent (%) relief of back and near resolution of her leg pain. She had two facet injections, one which was negative and three sacroiliac joint injections which one was very helpful. She had physical therapy a few years ago with a continued home exercise program. Her exam was normal. Her magnetic resonance imaging (MRI) was reviewed for a right paracentral protrusion contacting the traversing right sacral (S)1 nerve, Type II Modic changes at the inferior endplate of lumbar (L)5 at L5-S1. The assessment was vertebrogenic low back pain, and the Intracept procedure was recommended.

A lumbar MRI stated degenerative changes with anterior and posterior disc bulge osteophyte complexes, disc desiccation, and facet arthropathy. At L4-5 a posterior disc bulge making mild impression on the thecal sac, disc bulge, and facet arthropathy contributed to minimal right foraminal narrowing. At L5-S1 a broad based posterior disc bulge osteophyte complex making mild impression on the thecal sac, disc bulge osteophyte complex, and facet arthropathy contributed to mild left neural foraminal narrowing. There were mild endplate degenerative changes with mild T2 signal elevation involving the bone marrow adjacent to the L5-S1 endplates consistent with reactive edema associated with arthritic change.

At issue is whether outpatient Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
I uphold, in whole, the health plan's determination regarding the treatment.

The proposed treatment is not likely to be more beneficial than any standard treatment for the patient's condition.

She has low back and bilateral thigh and posterior leg pain with multiple pathologies in the lumbar spine at L4-5 and L5-S1 to include disc protrusions and facet arthropathy as well having positive responses to epidural steroid injections and one sacroiliac joint injection. It is unclear if her back pain is coming from the basivertebral nerve. Studies have specifically excluded patients with radicular pain or significant facet arthropathy. Therefore, the procedure may not be beneficial and would be considered experimental/investigational. It is unknown if there are long-terms adverse risks with the requested surgery over standard services or treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: lower back pain
Treatment: Outpatient Intracept Procedure
The insurer has denied the Outpatient Intracept Procedure. 
The health plan's determination is upheld.

The patient has low back pain. Magnetic resonance imaging (MRI) of the lumbar (L) spine showed L4- sacral (S)1 degeneration with foraminal narrowing.

At issue is whether outpatient Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
I uphold, in whole, the health plan's determination.

The Outpatient Intracept 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.

No large, long-term studies have shown clinical efficacy in this patient cohort with imaging showing ongoing foraminal stenosis at multiple levels. Thus, more studies are needed showing clinical benefit of Intracept.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anaphylaxis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a medical history significant for peanut allergy leading to anaphylaxis who was taken to the emergency department (ED) via Emergency Medical Services (EMS) after having an anaphylactic reaction at school. According to the records, she went to the nurse's office after entering a classroom and smelling peanuts. She reported that she was having an allergic reaction. She asked for her EpiPen and shortly after she collapsed and became unresponsive. Firefighters were on campus for career day and responded immediately, finding her pulseless and apneic. They applied an automated external defibrillator (AED) with no shockable rhythm. They performed cardiopulmonary resuscitation (CPR) for 15-20 minutes while awaiting EMS. When EMS arrived, she had a pulse with spontaneous respirations, so CPR was discontinued. She had a history of multiple visits to the ED with similar symptoms but no objective evidence of anaphylaxis.
No organic causes for the symptoms were identified and there were no findings consistent with a cardiac arrest. A psychiatry consultation was requested with recommendations to monitor the hospital "post arrest". Later, she admitted that she may have had a panic attack.
Admission orders included pediatric cardiology consultation, regular pediatric diet, and outpatient psychiatry follow-up. There was no indication of an inpatient psychiatry admission. She was being monitored for a recent panic attack. She remained stable. A repeat electrocardiogram was unremarkable. She had no further complaints except for some mild reproducible chest discomfort on palpation. She was deemed stable for discharge with recommended outpatient follow-up. At issue is the medical necessity of inpatient hospital admission.

No. Acute inpatient admission was not medically necessary.
This female patient had a history of a peanut allergy leading to anaphylaxis. She also had anxiety. Most recently she experienced symptoms of suspected anaphylaxis without any findings consistent with anaphylaxis. During this most recent episode, she reported smelling a trigger of peanuts, administered her EpiPen, and became unresponsive, but upon later questioning acknowledged experiencing severe anxiety and panic over one of her classes. She had no physical findings or lab findings consistent with anaphylaxis. She was subsequently evaluated by psychiatry without a recommendation for inpatient psychiatric hospitalization. She was monitored overnight and discharged home to follow up with psychiatry as an outpatient. While it was not unreasonable to monitor her overnight, she was overall hemodynamically stable with no evidence of airway compromise or gastrointestinal issues. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces, Monthly Visits, and Retainer
The insurer denied: Braces, Monthly Visits, and Retainer
The denial is overturned.

The patient is a teenage female. The review is for medical necessity of comprehensive orthodontic treatment.

The braces, monthly visits, and retainer are medically necessary.

The patient does have an automatic qualifier on the HLD (Handicapping Labio-Lingual Deviation) index of a crossbite of an individual anterior tooth. Tooth #27 is in crossbite, and 
there is thinning of the tissue around tooth #27. The request is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit, D8680 Retainer
The insurer denied: D8080 Braces, D8670 Monthly Visit, D8680 
Retainer
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic benefits, with monthly visits and retainer. The health plan's prior denial of coverage was due to the patient having a 
handicapping index score of 19. The patient has a Class I malocclusion with Class II canines. There is moderate upper and lower crowding with a deep bite.

The D8080 Braces, D8670 Monthly Visit, D8680 Retainer are medically necessary.

The patient has a crossbite of a lower anterior tooth (#22, lower left canine) with clinical attachment loss and gingival recession. This is an automatic qualifier according to the handicapping index scale. The monthly visits are to make sure treatment is progressing properly, and the retainer is used to prevent relapse. Therefore, the requested health service is medically necessary.