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

Diagnosis: Vertebrogenic Low Back Pain.
Treatment: Intracept Procedure (64628, 64629).

The insurer denied Intracept Procedure (64628, 64629).  The denial is upheld.

The patient is an adult female with chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. 

The patient has failed epidural steroid injections, medication management, and physical therapy. Magnetic resonance imaging (MRI) shows Modic changes. The patient's Physical exam does not reveal any neurological injury.

The health plan should not cover the Intracept procedure.

The patient is an adult female with chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed epidural steroid injections, medication management, and physical therapy. Magnetic resonance imaging shows Modic changes. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact, most recent articles show less than 50% (percent) improvement for the treatment of chronic low back pain with spinal fusion. However, the patient has not failed sacroiliac (SI) joint interventions, or facet interventions, which are common treatments of axial low back pain. In situations where all non-invasive options have failed, epidural steroid injections could also be considered, although typically used in patients with radicular symptoms. Spinal cord stimulation is also an alternative, however, has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk and can lead to addiction and overdose. Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. Therefore, the health plan should not cover the requested Intracept procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic Fibroids
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

The patient with a history of symptomatic fibroids and adenomyosis underwent a laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy. The procedure was uncomplicated. The blood loss was 100 milliliters (ml).

The patient was admitted for overnight monitoring. There were no acute events overnight and the patient was discharged.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.

Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing, or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:

1) Surgical complications (bladder ureter or bowel injury or hemorrhage) 2) Conversion to abdominal hysterectomy 3) Complex surgery (staging of endometrial cancer) 4) Wound complications 5) Comorbidities.

This patient had none of the above. The procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that a laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

Based on the above, the insurer's denial is upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Leg Pain and Swelling
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient in this case is an adult female who presented to the emergency department with right leg pain. She also complained of chest tightness. The patient had a prior history of venous thrombosis but only took anticoagulation for one week. Foot surgery was done one month before this visit. Evaluation revealed acute deep vein thrombosis (DVT) in the femoral vein, posterior tibial vein and popliteal vein. Computed tomography (CT) of the chest revealed a dilated pulmonary artery and bilateral pulmonary emboli. The patient's vital signs were notable for heart rate 111. Her blood pressure was normal. She was admitted to the hospital and placed on telemetry monitoring given her tachycardia. Echocardiogram was done and was unremarkable. The patient was started on Lovenox 80 milligrams (mg) every 12 hours and transitioned to Eliquis following that. Vascular surgery was consulted and recommended computed tomography (CT) angiography to look for May-Thurner 
syndrome. This test was done and negative. Pain in the right calf was managed with Tylenol. The patient was treated with one dose of vancomycin and four days of Keflex for suspected cellulitis, though records note that suspicion for cellulitis was low.

The proposed treatment was not medically necessary.

This patient was diagnosed with extensive lower extremity deep vein thrombosis (DVT) and bilateral pulmonary embolism. She did have mild tachycardia but was overall hemodynamically stable. There was no right heart strain. She was treated with anticoagulation in the standard fashion. She did not have any significant respiratory compromise and did not have any evidence of limb ischemia. She did not require acute care inpatient admission for management of her deep vein thrombosis and pulmonary embolism. She could have been safely managed with anticoagulation in the outpatient setting. Acute care inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

The patient is a woman with hypertension (HTN) and ethyl alcohol (ETOH) abuse who presented with chest pain, dizziness, palpitations and fatigue. Her blood pressure was 181/102 and pulse 155 beats per minute (bpm). Electrocardiogram (EKG) showed sinus tachycardia at 123 beats per minute (bpm), left ventricular hypertrophy and depolarization abnormality. 

The inpatient admission is not medically necessary.
Per standard guidelines, including Milliman, inpatient admission is medically indicated for "hypertensive emergency indicated by systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage, as indicated by 1 or more of the following: hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, acute kidney injury or other acute or worsening end organ damage due to severe hypertension." None of these conditions is present for this patient.
With regard to her chest pain, inpatient admission is indicated for patients with hemodynamic instability, respiratory distress, or chest pain with objective findings indicating a serious cardiopulmonary diagnosis, such as aortic dissection, pulmonary embolus, or acute myocardial infarction (MI). None of these conditions are present for this patient. The patient presented with chest pain and elevated BP, but did not have evidence for acute myocardial infarction, based on troponin or ECHO findings. She did undergo cardiac catheterization within the first 24 hours of admission, which was normal. Observation is appropriate, but not full inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, arthritis
Treatment: Personal Care Assistance (PCA) 24 Hour(s) (Live-In) per Day, 7 Days per Week
The insurer denied Personal Care Assistance (PCA) 24 Hour(s) (Live-In) per Day, 7 Days per Week.
The denial is overturned.

This elderly female patient has medical conditions that include dementia, arthritis, hypertension, and hypothyroidism. She lives alone. Denial of personal care assistance (PCA) 24 hours (live-in) per day, 7 days per week is being appealed. The health plan approved 5 hours per day, 7 days per week. Uniform Assessment System evaluation completed three months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances and medications, and shopping; extensive assistance with phone use and bathing; limited assistance with personal hygiene, dressing, walking, locomotion, and toileting; and supervision with bed mobility and eating. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, upper body dressing, toilet use, and bed mobility. A letter from the Provider notes the patient is homebound and requires constant assistance due to 
her clinical and mental decline. She needs assistance to include diaper change every two hours. Another letter notes the patient has hallucinations. She will remain in bed if no one helps her. She cannot call for help.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic conditions. Denial of personal care assistance (PCA) 24 hours (live-in) per day, 7 days per week is being appealed. The health plan approved 5 hours per day, 7 days per week. Uniform Assessment System evaluation completed three months shows the patient requires assistance with all activities of daily living, except bed mobility and eating. She is incontinent of bladder. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, upper body dressing, toilet use, and bed mobility. Appeals statements indicate the patient is homebound and needs assistance with all activities of daily living. She is unable to get out of the bed without assistance. She requires diaper changes every two hours. The information provided shows that this patient has significant limitations in functioning. The approved personal care aide (PCA) 5 hours per day, 7 days per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 24 hours (live-in) per day, 7 days per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood clot (pulmonary embolism)
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient in this case is an adult female who presented to the emergency department with abdominal pain, nausea/vomiting, and subjective fever with chills. The pain was sharp and located in the right upper quadrant and had been episodic for six months but worse over the past two weeks. The patient had deceased oral intake due to pain and nausea. The patient's vital signs and physical exam were unremarkable. Computed tomography (CT) was done and revealed pulmonary embolism. Chest x-ray and abdominal ultrasound were unremarkable. There was no clear explanation for her pain. The patient was admitted and started on Eliquis. On the day after admission, she felt well and noted improved abdominal pain. No acute issues were noted. The patient was continued on Eliquis and was discharged on the second hospital day.

The proposed treatment was not medically necessary.

This patient was diagnosed with a segmental versus sub-segmental pulmonary embolism. She had abdominal pain with a benign exam, unremarkable labs, and unremarkable imaging studies. She had no coronary ischemia, respiratory insufficiency, or other acute medical issues. She had no hemodynamic instability. Given these factors, acute care inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic back pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient had a history of hypertension, diabetes, partial hysterectomy, and chronic back pains. She presented with back pain, abdominal pain and constipation. She had a previous placement of a spinal cord stimulator 10 years earlier. An abdominal computed tomography (CT) scan was negative for acute disease. The spinal stimulator was in place. Lumbar (L)4/L5 laminectomies were noted. A myelogram was done. No neurosurgical interventions were advised. She was treated with gabapentin. Her hypertension was able to be controlled. Pain management was advised, and a Physical Therapy evaluation was done. A psychiatry consult was obtained for schizophrenia. She was determined to be stable for discharge for further rehab. 

Milliman Care Guidelines (MCG) M-63 lists clinical indications for admission for Back Pain. These include having an acute neurological deficit including cauda equina or conus medullaris syndrome. Other indications include having severe pain that requires an inpatient admission or conditions such as aortic dissection, epidural abscess, or spinal instability. The patient did not have these conditions. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bacteremia, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient required a workup and pain control for chronic back pain. There was no acute abdominal event, and no acute interventions were needed. The neurosurgical evaluation could have been done with observation status. She did not meet MCG criteria for admission for either Back Pain or Undiagnosed Abdominal Pain. 

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: Malpositioned Teeth
Treatment: Braces and monthly visits
The health plan denied: Braces and monthly visits
The determination is: Overturned

The patient is a male with an anterior crossbite on teeth 7 and 10. He presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. He is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.
At issue is the medical necessity of braces and monthly visits.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of braces and monthly visits is medically necessary for this patient. This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.[1,2,3] If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting and RLQ (right lower quadrant) abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adolescent male. He presented to the ED (emergency department) with vomiting and RLQ (right lower quadrant) abdominal pain. The patient was diagnosed with flu and was given IV (intravenous) fluids as well as IV (intravenous) Zofran. The patient continued to have abdominal pain and emesis and was unable to tolerate an oral challenge. The patient had an elevated heart rate as well as an elevated respiratory rate. The patient was admitted due to their inability to tolerate oral intake. He was weaned off of IV (intravenous) fluids once he was able to tolerate oral intake. He was subsequently discharged with follow up with their doctor planned.

The Inpatient Hospital Admission was medically necessary.

The patient was noted in the ED (emergency department) to receive IV (intravenous) Zofran x (times) 2, and he was noted to have failed an oral challenge after that treatment, which is the gold standard for emesis and nausea. With the documented pathology of right lower quadrant pain as well as the possibility of a food borne illness and a known flu infection, there were a variety of pathologies that could have created this clinical scenario, and each could have had a varying effect on the patient's electrolyte balance as well as duration of their symptoms. If the patient were to have had a change in their abdominal pain, that could lead to a further pre surgical work up. If blood were to have developed in their stool, that could point to other infectious etiologies. If the emesis were to have worsened and the patient were to have had blood with a possible esophageal injury, that would be another set of treatment plans required. As the patient demonstrated continued emesis, and no ability to tolerate PO (by mouth), it was the best clinical plan to admit the patient for monitoring to ensure that the patient's clinical status did not worsen. The admission was medically necessary, and the care was medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Encounter for colonoscopy
Treatment: Colonoscopy performed in hospital
The insurer denied: Colonoscopy performed in hospital
The denial is upheld.

This is an adult female who underwent colonoscopy. No medical records are included in the documentation describing the indication for the procedure.

The proposed treatment was not medically necessary.

There is no support for medical necessity. Colonoscopy performed at a hospital-based facility may be indicated in high-risk individuals such as morbid obesity, sleep apnea, severe heart or lung disease. There is no documentation of such.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a male with poorly controlled diabetes mellitus (DM), and hypertension (HTN) who presented to his primary care physician (PCP) not feeling well for the past month. One month ago, he reported dizziness and headache and has not felt well since. He was found to have an elevated blood sugar at his PCP's office so was sent to the hospital. 

The inpatient hospital admission was not medically necessary based on the documentation provided. The patient presented after he was found to have an elevated glucose at his primary care's office. He had not been feeling well for about a month and had some prior dizziness and headaches. He was hypertensive but otherwise hemodynamically stable and not in any acute distress. His blood sugar was elevated at 385. He did not have any mental status changes. He did not have any severe electrolyte or metabolic abnormalities. He did not have a blood glucose of greater than 500. He did not have diabetic ketoacidosis (DKA) or hyperosmolar diabetic coma. He did not have hypertensive emergency. He did not have acute kidney injury. He did not have severe dehydration requiring inpatient volume repletion. He did not have severe or persistent nausea or vomiting. He did not have a worsening of his clinical condition and his blood sugars improved expectantly. There was no other documented clinical finding that required inpatient management or monitoring. He could have been managed at a lower level of care with subsequent outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypotension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This patient presented to the hospital after the patient was noted to be lethargic and hypotensive at their doctor's office.  The patient complained of weakness and lightheadedness and blood pressure was 70/40.  The patient was undergoing preoperative evaluation prior to planned prostate surgery. Past medical history was significant for prostate cancer.  Emergency Medical Services (EMS) administered intravenous (IV) fluids and symptoms resolved.  On arrival to the hospital, vital signs were stable (blood pressure 121/61, pulse 112). Physical examination revealed no significant abnormalities.  12 lead electrocardiogram (ECG) demonstrated sinus tachycardia with a prolonged QTc interval (500 milliseconds (msec)).  Serum blood testing demonstrated acute kidney injury with blood urea nitrogen (BUN) 19 and creatinine 2.3, hypokalemia (3.4), microcytic anemia with hemoglobin of 11.2 and normal troponin levels (13.9). The patient was admitted to the hospital for observation and treatment. The patient was treated with intravenous fluids, potassium and magnesium. Following treatment, QTc normalized, and the patient was discharged home.

This patient presented with lightheadedness and near syncope. Given a prolonged QTc interval on electrocardiogram, cardiac syncope was a concern.  The patient was also treated with intravenous fluids as their acute renal failure was likely due to volume depletion.  Potassium and Magnesium supplementation with cardiac monitoring was also necessary.  This patient falls into a moderate risk group for syncope.  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, hypomagnesemic, hypokalemic and with a prolonged QT interval on electrocardiogram. It is likely that the etiology of syncope was volume depletion.  Admission to the hospital for treatment and risk stratification was medically necessary in this case.

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 an inpatient admission is substantiated.