Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: pelvic pain.
Treatment: Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins.
The insurer denied Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins.
The health plan's determination is overturned.

The patient is a female with pelvic pain, and vulvar varicosities severely limiting quality of life. She has painful menstruation and intercourse. Imaging suggests the presence of significantly dilated ovarian veins, left iliac venous compression, and left renal vein compression. These symptoms and imaging findings are consistent with the described and established syndrome of pelvic congestion.

The proposed Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins is likely to be more beneficial than any standard treatment option. Given the imaging findings and clinical scenario there is no role for a much more invasive laparoscopy. The patient would benefit from the proposed ovarian/internal vein embolization/occlusion. This treatment option has been well documented in peer-reviewed literature over the decades.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: pelvic pain.
Treatment: Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins.
The insurer denied Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins.
The health plan's determination is overturned. 

The patient is a woman who was evaluated for pelvic symptoms. The patient presented with pelvic discomfort, sharp right lower quadrant/inguinal pain requiring an emergency department (ED) visit, severe dyspareunia predominantly after sexual intercourse, urinary frequency, and mild hemorrhoids. The patient was told that she may have pelvic congestion.

The requested treatment, endovascular occlusion/sclerotherapy of the ovarian and/or internal veins, is likely to be more beneficial than any standard treatment or treatment for the insured's life-threatening or disabling condition or disease.
The patient has pelvic congestion syndrome. The recommended treatment is the treatment of choice and is the standard of care for the treatment of pelvic congestion syndrome.
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: pelvic pain
Treatment: Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins.
The insurer denied Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins
The health plan's determination is overturned. 

The patient is a female with a chief complaint of 5 years of diffuse pelvic pain since the birth of her 4th child with severe dyspareunia. She was seen in an emergency room (ER) with severe right lower quadrant (RLQ) pain with no acute intraabdominal process seen on abdominal computed tomography (CT). The patient is being treated for overactive bladder by a urologist with Ditropan. She underwent a tubal ligation.
A pelvic ultrasound was performed, and it was without significant pathology. A CT venogram of the abdomen/pelvis was performed which was reported as showing: moderate narrowing of the left common iliac vein; the right ovarian vein dilated to 10 millimeters (mm) in diameter; the left ovarian vein mildly dilated to 6mm superiorly; the left renal vein severely narrowed; mildly prominent peri-uterine veins and prominent veins of the labia.

Endovascular Occlusion/Sclerotherapy of the Ovarian and/or Internal Veins is likely to be more beneficial than standard treatment for this patient. 
The systematic review by Brown et al. (2018) reviewed 14 studies and 828 women found an improvement in clinical symptoms of pelvic congestion syndrome after endovascular ovarian vein treatment ranging from 68.3 to 100%. In another systematic review - Hansrani et al (2015) - a statistically significant decrease in pelvic pain was reported in 9 of 13 studies. Daniels et al. (2016) analyzed 22 cohorts involving 1,308 patients and the average rate of symptom improvement within the first 3 months was 75%.
Based on this literature, the endovascular occlusion/sclerotherapy of the ovarian veins is more likely to be beneficial for the patient's pelvic congestion syndrome.
Appeal type: Medical necessity
Decision: Upheld

Skin
Inpatient hospital

Diagnosis: Skin infection
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male who, since about a week ago, possibly after bug bite or pimple or other lesion in his right cheek area which he tried to pop by himself and in the process, apparently scraped his skin and caused an opening, incurred increasing painful swelling and redness of this region extending near his right orbit. There was no loss of consciousness. Apparently, he was seen by his primary physician since three days ago and started on Bactrim and subsequently seen by an ear, nose, and throat (ENT) specialist who told him that this was not a sinus related issue and was seen by dermatologist who finally referred him to the Emergency Room. 

An inpatient hospital admission was not medically necessary.
This patient had a facial infection but was not septic. He could have received intravenous (IV) antibiotics and incision and drainage at a lower level of care.
According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable and needed only IV antibiotics and incision and drainage. He could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized Body Swelling (belly, face, breast and legs)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult female. She was diagnosed with generalized body swelling (belly, face, breast, and legs). This request is for coverage of admission. The patient has a history of Grave's disease. She had stopped taking her medications six months prior. The patient presented to the emergency room with a complaint of multiple sites of intermittent swelling (abdomen, legs, face, breast) for a month. The patient had had a similar presentation in the past. The patient had palpitations and generalized weakness. Vital signs were blood pressure 139/88, heart rate 109, and respiration 16. An electrocardiogram (EKG) showed atrial fibrillation. A chest X-ray showed likely persistent cardiomegaly. Labs revealed thyroid stimulating hormone (TSH) lower than 0.008, T4 (Thyroxine) free 3.06, T3 (Triiodothyronine)-total 299, Thyroglobulin antibodies 373.5, thyroid peroxidase (TPO) (microsomal) 215.5, D-dimer 1.15, and brain natriuretic peptide (BNP) 230.18. On day #2 labs revealed total bilirubin 1.4, alkaline phosphatase 447, aspartate aminotransferase (AST) 37, and albumin 2.1. The patient was admitted for severe symptomatic hyperthyroidism with thyrotoxicosis without thyroid storm.

The Inpatient admission was medically necessary.

Admission to the hospital for telemetry and treatment is necessary for any patient with a Burch-Wartofsky score of greater than 24 (1-5). The patient had impending thyroid storm with a score of 30. The patient had atrial fibrillation, tachycardia, edema, and hepatic dysfunction. Admission to the hospital is consistent with generally accepted standards of medical practice. The patient was appropriately treated. The patient was safely discharged once her symptoms and vital signs improved. The inpatient admission was, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve Treatment (Ablation)
The insurer denied: Nerve Treatment (Ablation)
The denial is upheld.

This patient is an adult male with low back pain that began over 3 years ago. Past treatments have included: facet injections, radiofrequency ablation, home exercise, and over-the-counter medications. The pain is affecting the patient's ability to perform activities of daily living. Magnetic resonance imaging (MRI) of the lumbar spine shows Modic type 1 changes at L5-S1, chronic L5 pars defect with grade 1 anterolisthesis of L5 on S1, severe bilateral foraminal narrowing with mass effect on the bilateral L5 nerve roots, and new mild canal stenosis and worsening of disc space narrowing at L5-S1 versus 2020 magnetic resonance imaging. The request for Intracept was denied as not shown to be effective to treat this pain and as such not medically necessary.

The requested health service is not medically necessary.

A review of the literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. Furthermore, in this clinical case, this patient has other causes of low back pain that have not been excluded on magnetic resonance imaging as likely causes of pain. As such, the Intracept procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This male patient was hospitalized for chest pain. He presented to the emergency department for evaluation of chest discomfort and left flank pain. His vitals were stable, and exam was normal. 
The patient's past medical history was significant for known coronary artery disease (CAD) with recent percutaneous coronary interventions (PCIs) several months ago, coronary artery bypass graft (CABG) time four (x4) vessels last year, hypertension, hyperlipidemia, diabetes with an insulin pump, neurofibromatosis, and severe peripheral arterial disease (PAD) with toe amputations and angioplasties. Left heart catheterization with grafts from several months ago showed 3-vessel coronary artery disease (right coronary artery [RCA], left anterior descending [LAD], left circumflex [LCx]), occluded left internal mammary artery (LIMA) to left anterior descending artery and jump to first diagonal artery (D1), patent right internal mammary artery (RIMA) to left circumflex first obtuse marginal artery (OM1), patent graft to left circumflex second obtuse marginal artery (OM2), mildly depressed left ventricle (LV) systolic function, and successful intervention to mid left anterior descending artery with drug-eluting stent (DES). The patient's electrocardiogram (EKG) was without ischemic changes. His chest X-ray was normal. Troponin panel was negative. Transthoracic echocardiogram showed an ejection fraction of 41 percent and no pericardial effusion. Toprol XL was increased to 100 milligrams (mg) by mouth daily, and the patient was discharged home. The requested coverage for Inpatient Hospital Admission was denied based on the policy and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, including the provided Milliman Care Guideline (MCG) criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received for chest pain with stable coronary artery disease like in this case is routinely provided safely and effectively at a lower level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is an adult male. He presented to the hospital emergency department with complaint of abdominal pain for two days. He had been in the emergency department two days prior, and an umbilical hernia was reduced at that time. Past medical 
history included a ventricular septal defect repair. The patient's vital signs were normal at the time of presentation to the hospital. 

The records indicate that the patient underwent repair of an incarcerated umbilical hernia with mesh. The hernia defect size was 4 centimeters. A 1.7-inch (4.3 centimeters) Ventralex mesh patch was used for the repair. The records note that the operation required 59 minutes to complete. The patient was monitored in the hospital following surgery. The patient remained hemodynamically stable with normal vital signs following surgery. Pain was well controlled with oral medications. The diet was advanced. The patient was deemed to be stable for discharge from the hospital on the same day. The submitted documentation references InterQual 2023 Acute Adult General Surgical. The 
health plan rationale for denial is that the care provided from could have been rendered with a lower level of care than inpatient status as there was no complication or comorbidity related to this episode of care. The health plan's denial is being appealed.

The inpatient admission was not medically necessary.

This patient had a 4-centimeter incarcerated ventral hernia. The patient presented to the hospital emergency department due to pain related to this hernia. He was hemodynamically stable at the time of presentation. He underwent operative repair of the umbilical hernia on the same day. The operation to repair the ventral hernia was performed without complication. The submitted records document clinical stability in the perioperative period and that the patient met criteria for discharge from the hospital following surgery. While the operation was performed following his presentation to the emergency department, it was completed without complication, and the patient was able to be advanced on diet and oral pain management following surgery. Generally accepted guidelines for patient care state that inpatient stay is needed for hemodynamic instability, peritoneal signs, suspected acute mesenteric ischemia, signs of obstruction, surgical complications, or other clinical issue that requires inpatient confinement. In this case, there was no documentation to support that these criteria were met to warrant an inpatient level of care. The operation was completed without complication and the patient responded promptly and favorably to the therapy provided. The patient was stable for discharge from the hospital on the same day as surgery was performed. The care during this time could have been rendered with a lower level of care. This lower level of care would have been consistent with the referenced InterQual guidelines and with generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: Continuous Glucose Monitoring (A4239) includes 
all Supplies and Accessories, 1 Month Supply = 1 Unit of Service
The insurer denied: Continuous Glucose Monitoring (A4239) includes all Supplies and Accessories, 1 Month Supply = 1 Unit of Service
The denial is upheld.

The patient is an adult male with a diagnosis of type 2 diabetes mellitus without complications. His glycated hemoglobin (A1C) was 6.4% (percent) several months ago and 9.4% last year. According to the documentation, the patient takes Farxiga 5 milligrams daily, Metformin 500 milligrams daily and Trulicity once per week. He has a history of thyroid cancer and thyroidectomy, currently taking Synthroid. The provider prescribed continuous glucose monitoring.

The requested health service is not medically necessary.

Continuous glucose monitoring (CGM) has been demonstrated to be clinically valuable, reducing risks of hypoglycemia and hyperglycemia, glycemic variability (GV), and improving patient quality of life for a wide range of patient populations and clinical indications. Use of continuous glucose monitoring (CGM) can help reduce glycated hemoglobin (HbA1C) and mean glucose. 
One continuous glucose monitoring (CGM) device, with accuracy (% mean value of the absolute relative differences [MARD]) of approximately 10%, has recently been approved for self-adjustment of insulin dosages (non-adjuvant use) and approved for reimbursement for therapeutic use in the United States. Continuous glucose monitoring (CGM) had previously been used off-label for that purpose. Continuous glucose monitoring (CGM) has been demonstrated to be clinically useful in both type 1 and type 2 diabetes for patients receiving a wide variety of treatment regimens. Continuous glucose monitoring is beneficial for people using either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). (Rodbard 2017)
The patient in this case has well controlled type 2 diabetes and is not on insulin therapy. His last glycated hemoglobin (A1C) was less than 7.0% which is consistent with good glucose control. 
There is no documentation of recurrent hypoglycemia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vascular Disease.
Treatment:  Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

This is a female patient for whom an inpatient hospitalization is under review. She was admitted electively for vascular disease and underwent a successful and uncomplicated lower extremity angiography and intervention of the left anterior tibial, popliteal, and tibial-peroneal trunk vessels. The creatinine was normal. The blood pressure (BP) was elevated. Other vital signs and the oxygen saturation were essentially normal. The patient remained stable and was discharged. At issue is the medical necessity of an inpatient admission.

This patient underwent successful elective and nonemergent lower extremity arterial stenting without complications, and was monitored for an adequate post procedure period. There were no vascular complications, hemodynamic instability, acute recurrent limb ischemia, need for emergent surgery, or need for prolonged intravenous medications. The creatinine was normal. In this setting, an inpatient hospitalization, compared to for example outpatient, has not been established instead of care towards improved peripheral vascular disease (PVD) outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Damaged tooth.
Treatment: C2750 White Glass with High Gold Content Crown, Tooth 8.

The insurer denied C2750 White Glass with High Gold Content Crown, Tooth 8.  The denial is upheld.

The patient is an adult male. The request is for a crown on tooth # (number) 8. The tooth has small filling on the lingual (back) surface showing up on the x-ray provided. The health plan denied coverage of the request due to there not being any damage to the tooth requiring a crown to restore it. The denial is being appealed.

The requested health service is not medically necessary.

Tooth #8 does not have any fractures or recurrent decay showing up on the x-ray. There is evidenced to be a good amount of solid tooth structure present. No crown is needed to restore the tooth based upon the x-ray provided. The documentation mentioned that tooth #8 was to have or has had a root canal procedure done, but there are no x-rays presented to confirm that this was done. Without this confirmation of a root canal procedure, the medical necessity of the crown cannot be confirmed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: braces and monthly visits
The insurer denied braces and monthly visits.
The determination is upheld.

The patient is a female with a Class II occlusion. She has approximately a 2 millimeter (mm) overbite and 1 mm overjet. She has minor crowding and is congenitally missing teeth 7 and 10. Tooth 19 is missing due to tooth extraction. Teeth 6 and 11 have erupted in the position where 7 and 10 should have been. The narrative states she has an anterior crossbite with attachment loss. She is treatment planned for 24-30 months of orthodontics to create space for implant replacement of 7 and 10. At issue is the medical necessity of braces and monthly visits.

There is no medical reason to correct her malocclusion with braces. While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. Studies have shown that canine substitution (which is how the patient is presenting currently) is often an ideal way to handle missing missing maxillary lateral incisors. (2) If the patient does not like the shape of her maxillary canines, a dentist can restore them to a more esthetic shape. (2) If her teeth were aligned, it may provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.