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

Diagnosis: Accidental Poisoning

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is a toddler who presented after accidental ingestion of Amlodipine. The heart rate (HR) was 118 and blood pressure (BP) at lowest was 88 mm Hg (millimeters of mercury) systolic. As per Pediatric Advanced Life Support (PALS) criteria, the 5th percentile BP is 70 + 2 x age; hence the BP that would be concerning would be 74 mm (millimeters) of less. Hence the 88 mm of systolic pressure was normal for age. There were no mental status changes, no hemodynamic changes and no need for pressors. The half-life of the amlodipine is 4 hours, the strength of the tablet is 5 mg and patient's weight was 15 kg (kilograms). The mg/kg (milligrams/kilograms) dose was 0.33 mg/kg. The fatal dose is > 2 mg/kg. In one study, Children who ingested > 10 mg were 4.4 times more likely to develop clinically important responses than those ingesting < or = 5 mg.

The patient could have been monitored in the emergency department (ED) for 8 hours or observed in the ED/Observation unit for 24 hours safely with intent to transfer to acute care if the BP or HR consistently decreased. 

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: Pneumonia

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

The patient is an adult with multiple medical issues. There is a history of depression and esophageal stricture secondary to caustic ingestion during a suicidal attempt. The patient had esophagogastrectomy and gastrectomy with colonic interposition. The patient has a past medical history of pulmonary embolus (PE) and cocaine abuse.  The patient presented to the emergency room with complaints of (C/O) shortness of breath (SOB), fever, and chills. The patient also reported some vomiting for 1 day. Sore throat and dysphagia were reported.  The patient reported some aspiration like symptoms for 2 days.

At presentation to emergency department (ED), he was febrile to 103.3 degrees Fahrenheit respiratory rate 26, heart rate 114, blood pressure 124/75 mmHg (millimeters of mercury), and oxygen saturation 94% (percent). Lungs clear and heart sounds normal. Labs included an elevated white blood cell count (WBC) 13.6, Hemoglobin 10.2 and Lactate 3. Electrolytes were within normal limits. Sepsis trigger occurred. The patient was given broad spectrum antibiotics and intravenous fluids. Computed tomography angiogram was done. There was no pulmonary embolism. Bilateral ground glass opacities consistent with some inflammatory changes/pneumonia were noted.  The patient was admitted with the diagnosis of community acquired vs aspiration pneumonia.

The patient remained stable after admission. By the next day, the patient was afebrile and hemodynamically stable. WBC was 10 and lungs were clear.  The patient had a modified Barium swallow which was normal. No evidence of aspiration was documented. The patient was recommended a normal diet.  This patient was kept on antibiotics for a few more days and discharged home on oral medications.

This patient did not need acute hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient could have been in observation for up to 48 hours while being treated with IV fluids and  (intravenous) IV antibiotics. The patient was in no acute distress with oxygen saturations of 97 % on room air and lungs were clear. The patient was able to tolerate food and fluids. The patient was stable to be discharged home on oral antibiotics with close follow up in the outpatient setting.

The pneumonia was not severe with a CURB 65 (confusion, uremia, respiratory rate, BP [blood pressure], age >= 65 years) score of zero. The patient could have been treated briefly in the Observation setting with IV antibiotics and IV fluids, and then subsequently discharged home on oral antibiotics with close follow up in the outpatient setting.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis of the left elbow

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This patient has a past medical history significant for diabetes, hypertension, non-ST elevated myocardial infarction, coronary artery disease, CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome, gout, hyperlipidemia, abscess of the abdominal cavity, anemia, Barrett esophagus, gastroesophageal reflux disease (GERD), irritable bowel syndrome, peptic ulcer, and ventral hernia who presented to the emergency room with complaints of fever, left elbow pain, and swelling.

Vitals on presentation included: Temperature. 97.7 degrees Fahrenheit, Blood Pressure-97/63, Pulse-74, Respiratory Rate-18, oxygen saturation 100% on room air. Laboratory values were notable for the following: White Blood Cells-5.7, Hemoglobin-10.7, Hematocrit-33.3, creatinine-1.03, glucose-142. 

Patient was admitted for cellulitis of the left elbow and was started empirically on antibiotics (vancomycin, ceftriaxone, clindamycin). X-ray of elbow showed calcifications, and soft tissue swelling. Infectious Diseases consulted. Patient had an incision and drainage procedure. Cultures remained negative. Patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (doxycycline) as an outpatient.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Implantable Peripheral Nerve Stimulation (PNS) Device
The insurer denied Implantable Peripheral Nerve Stimulation (PNS) Device.
The health plan's determination is upheld. 

The patient is a female with complaints of low back pain. There is associated numbness in the bilateral hips. The pain is aggravated by standing, walking and bending. An magnetic resonance imaging (MRI) lumbar spine demonstrates L (lumbar) 4-L5 and L5-S (sacral) 1 disc bulges.

The proposed Peripheral Nerve Stimulation Device is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The patient has complaints of low back pain. Peripheral nerve stimulation involves placing a small electrical device (a wire-like electrode) next to one of the peripheral nerves. These are the nerves that are located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles/paresthesias. This modality is not recommended until there is higher quality research, including research on adverse events. The supporting evidence is limited to case reports, retrospective reviews, and small case series. Given the lack of support in the medical literature, the requested peripheral nerve stimulator is not appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Implantable Peripheral Nerve Stimulation (PNS) Device
The insurer denied Implantable Peripheral Nerve Stimulation (PNS) Device.
The health plan's determination is upheld. 

This patient is a female who has a complaints of (c/o) lower back pain. Her back pain started without significant precipitating event. The pain is described as sharp, shooting, heavy with numbness and radiating pain to the hip. Her pain is aggravated by standing, walking, and bending. She had tried pain medications and physical therapy (PT). According to the provided medical record, her diagnosis are neuralgia and spondylosis without myelopathy and radiculopathy. She underwent radiofrequency ablation with short-term pain relief. Physical exam (PE) was unremarkable except lumbar spine pain with flexion and extension, and positive facet loading tests. 

The Implantable Peripheral Nerve Stimulation (PNS) Device is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This patient has chronic back pain with the diagnosis of spondylosis. There are clinical evidence to support the efficacy of PNS for chronic migraine headaches via occipital nerve stimulation, chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles, failed back surgery syndrome via subcutaneous peripheral field stimulation and lower extremity neuropathic and lower extremity post-amputation pain. However, there is no clinical evidence for Implantable Peripheral Nerve Stimulation (PNS) Device in the management of chronic back pain secondary to spondylosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Implantable Peripheral Nerve Stimulation (PNS) Device
The insurer denied Implantable Peripheral Nerve Stimulation (PNS) Device.
The health plan's determination is upheld. 

This is a female patient with diagnoses that include Neuralgia and Neuritis Unspecified and Spondylosis without Myelopathy or Radiculopathy (Lumbar Region). It was noted that the patient complains of pain in the lower extremity and described as sharp, shooting, heavy, numbness in the bilateral hips and continuous. Lumbar spine magnetic resonance imaging (MRI) showed L (lumbar) 4/L5 and L5/S (sacral) 1-disc bulges. 

The Implantable Peripheral Nerve Stimulation Device is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The records indicate that the patient has a history of chronic back pain with symptoms into the lower extremities and it was noted that on MRI the patient has disc bulges at L4/L5 and L5/S1. The provider states the patient has failed conservative treatment including physical therapy, over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs), from a suitable therapy including but not limited to gabapentin, and has been taking opioids. However, peripheral nerve stimulation and specifically the requested system are not recommended and are not standard of care. There is no evidence to suggest that this treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain

Treatment: Intracept procedure

The insurer denied coverage for Intracept procedure

The denial is upheld.

This is an adult male with chronic low back pain. His medication trials have included Diclofenac, Flexeril, Gabapentin, Ibuprofen, and Oxycodone. He has done Physical Therapy. He has had Medial Branch Blocks and Epidural Steroid Injections with only short-term relief.  His magnetic resonance imaging (MRI) shows Modic changes at lumbar (L) 5- sacral (S) 1 along with a Disc protrusion at L2-L3 and neuroforaminal stenosis at bilaterally at L5-S1.  He has not had a surgical consultation.

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:

1)	Industry funding is a potential source of study bias for the available data reviewed
2)	Limited number of studies
3)	Short-term follow up for the majority of studied patients
4)	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 randomized controlled trials (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 radiofrequency (RF) ablation in the management of chronic lower back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

The unknown issues are long term outcomes, e.g. is there an increase in vertebral body fractures in the future, is there more osteopenia in treated versus untreated patients. 

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.

The carrier's denial of Intracept procedure should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Nerve Treatment in the Spine
The insurer denied: Nerve Treatment in the Spine
The denial is overturned

The patient is an adult female with chronic axial low-back pain for several years. She has had multiple treatments that have not provided long-term pain relief and functional improvement, including activity modification, home exercises, injections, medial branch block injections, medication management with NSAIDs (nonsteroidal anti-inflammatory drugs) and muscle relaxants, physical therapy, and radiofrequency ablations. The pain has had a significant impact upon ADLs (activities of daily living), such as walking. The severity of pain on VAS (Visual Analogue Scale) ranges between 2/10 and 8/10. The patient had an MRI (magnetic resonance imaging) twice that demonstrates mixed Modic type I and 11 changes consistent with Modic at disc  space Lumbar (L)4-L5. As such, her chronic Iow back pain is coming from the vertebrogenic change at L4 and L5. The Intracept procedure was recommended by the treating provider, but it was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The requested Nerve Treatment in the Spine is medically necessary.

The Intracept procedure is FDA (United States Food and Drug Administration) approved, and there is enough data in the medical literature to show it is safe and effective in the treatment of vertebrogenic low back pain. The medical documentation confirms that the patient has vertebrogenic mediated low back pain. Also, she meets the inclusion and exclusion criteria for the procedure, which include pain levels at least 3/10, chronic low back pain, MRI (magnetic resonance imaging) confirmation of vertebrogenic pain, and lack of response to appropriate conservative management. A prospective, randomized, multi-center study by Khalil et al in 2019 and another prospective, randomized, multi-center study done by Fischgrund also in 2019 both presented high quality evidence of efficacy and safety of the procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Pain

Treatment: hyaluronan injections

The insurer denied coverage for hyaluronan injections

The denial is upheld

This is an adult with a history of right knee pain and right knee arthroscopy with partial lateral meniscectomy. The patient presented to the Sports Medicine physician for a follow up visit months after a right knee partial lateral meniscectomy. The patient had undergone two arthroscopic procedures after being involved in a traumatic event. 

The patient complained of medial joint line pain following exercises. Overall, the patient was doing well. She reported mild discomfort with running. The physician recommended a corticosteroid injection to the right knee and continuing physical therapy (PT). A magnetic resonance imaging (MRI) scan showed intact articular cartilage, no meniscal tears and no effusion. An X-ray was unremarkable. Hyaluronan injections were recommended. 

The medical records demonstrate the patient has ongoing knee pain. A diagnosis is not known. The report of "ongoing scar" and need for the injection has no credence. The literature has recommended use of hyaluronan injections to aid in the management of osteoarthritis. 

There is no evidence that the patient has arthritis. Specifically, her symptoms are inconsistent for the diagnosis such as stiffness, swelling, limitation motion. Her physical examination did not show crepitus nor effusion. Her X-rays and MRI did not show arthritis. Her intraoperative description of the knee joint did not show arthritis. 

Based upon no specific diagnosis of osteoarthritis, there would be no indication for the injection. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hyaluronan injections is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Incontinence.
Treatment:  Consumer Directed Personal Assistance Program (CDPAP) 24 hours live-in services.

The insurer denied Consumer Directed Personal Assistance Program (CDPAP) 24 hours live-in services.  The denial is overturned.

The patient is a female with medical history notable for incontinence, gait difficulty, diabetes, congestive heart failure, atrial fibrillation, and hypertension. The patient is currently approved for 11 hours per day, 5 days per week and 7 hours per day, 2 days per week (total of 69 hours per week) of Consumer Directed Personal Assistance Program (CDPAP). The patient and her care team requested an increase to 24 hour live-in services, 7 days per week, and this request was denied by the health plan. This denial is the subject under review.

The requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) 24 hours live-in services is medically necessary for this patient.
The patient is unable to complete any ADL's or Instrumental activities of daily living (IADLs) independently. Her care needs cannot be scheduled into a personal care aide shift. She will need assistance with toileting as needed throughout the day and night. Furthermore, she has incontinence and will require changing of diapers at unscheduled times. For her to be safely transitioned back to her home in the community, she will require live-in personal care. This care is medically necessary to support her personal care needs. Failure to provide for these functional needs could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with a history of asthma. The presenting complaints were wheezing and shortness of breath. She had previously presented to an urgent care center several days prior and was prescribed prednisone and azithromycin but her symptoms continued to progress. She was using duonebs frequently as well. She also began to develop a cough, chest pain, and a fever. The physical exam was notable for no respiratory distress, diffuse wheezes. Lab results were notable for a white blood cell count (WBC) of 24. Radiology was notable for a chest x-ray without infiltrate. She was admitted to an inpatient level of care where she received steroids and duonebs, and was discharged home.
At issue is the medical necessity of an inpatient stay.

No. An inpatient stay was not medically necessary.
The patient presented with a mild to moderate asthma exacerbation most likely triggered by a viral respiratory infection. Outpatient management would have been inappropriate given her recent urgent care presentation. There was no documentation of emergency department (ED) reassessment after nebulizer therapies and steroids were delivered. The patient did not demonstrate respiratory distress, an inadequate response to therapies delivered in the ED, or documented social determinants of health that would have made a lower level care inadequate. A lower level of care would have been the most appropriate to ascertain the patient's response to initial therapy, with triaging to an inpatient level of care if necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee pain and swelling
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a female patient with a past medical history (PMH) of hypertension (HTN), hyperlipidemia, coronary artery disease (CAD), diabetes mellitus type 2 (DM2), congestive heart failure (CHF), gout, and asthma who was admitted with complaints of (c/o) left knee pain and swelling. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD) and left knee swelling with effusion. Lab work was notable for hyperkalemia. Imaging studies included a chest x-ray (CXR) which showed right basilar opacities, a left knee radiograph which showed soft tissue swelling with possible ulceration anterior to the patellar tendon. The patient was diagnosed with gout and treated with oral pain medications, steroids, and colchicine. The patient refused arthrocentesis and was empirically treated for septic arthritis, in addition to gout, although orthopedics felt the diagnosis was most likely gout. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with complaints of (c/o) left knee pain. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, did not meet systemic inflammatory response syndrome (SIRS) criteria, there was no animal or human bite with extensive damage, pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with prednisone, physical therapy, and pain control, and this could have been safely provided at a lower level of care. Orthopedics evaluated the patient and felt that gout was the most likely diagnosis, in spite of no successful arthrocentesis. A lower level of care would have allowed for frequent reevaluation to assess response to therapy while avoiding inpatient admission in this stable patient. Overall, this patient could have been safely treated at a lower level of care than inpatient.