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

Diagnosis: Low back Pain.
Treatment: Intraosseous basivertebral nerve ablation.
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male with complaints of chronic low back pain. Prior treatments have included activity modification, chiropractic care, home exercises, lumbar injections, as well as therapy. The pain is rated as high as 6 out of 10. The pain impacts activities of daily living. Magnetic resonance imaging (MRI) demonstrated Modic type II changes at lumbar (L) 5 and sacral (S) 1. Intraosseous basivertebral nerve ablation is under review.

The proposed health service or treatment of Intraosseous basivertebral nerve ablation 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. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended.
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in a decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is a lack of data to recommend this procedure as a treatment modality. In general, there is a lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment of Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastroenteritis.
Treatment:  Inpatient Hospital Stay.

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

The patient is a female with a past medical history of diabetes, coronary artery disease (CAD), and hypothyroidism, who presented to the emergency department (ED) for abdominal pain, nausea, vomiting, diarrhea and a decrease in by mouth (PO) intake. The review of systems was negative for additional symptoms.
The patient was afebrile (temperature of 37.1 degrees Celsius). The physical examination was unremarkable for positive clinical findings.
The patient was admitted for acute gastroenteritis. A computed tomography (CT) scan of the abdomen revealed no acute pathology. The patient was treated with intravenous (IV) fluids and supportive care. At issue is the medical necessity of an inpatient level of care.
The requested health service/treatment of inpatient hospital admission was not medically necessary.
The patient was admitted for acute gastroenteritis. The patient had a computed tomography (CT) scan and ultrasound without evidence of remarkable findings that required inpatient admission. Additionally, the patient did not have systemic signs of infection such as fever or elevated white cell count. Patients with viral gastroenteritis can be appropriately management as outpatients, if there is no evidence of hemodynamic instability or electrolyte derangements. The patient did not have an indication for inpatient admission. The patient also did not have a history of comorbid conditions or immunocompromised status that would place her at risk for dehydration or complications.
Most cases of viral gastroenteritis last only a few days, and therefore affected persons do not commonly seek medical attention. Antibiotics or other specific medications are typically not used to treat viral gastroenteritis. The goal of treatment is symptom relief and avoiding complications. Most cases do not require specific treatment and self-resolve. The treatment is usually supportive care. Hospital admission is indicated for severe cases that are associated with dehydration or evidence of electrolyte derangements.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with a Class II Division 1 malocclusion with maxillary and mandibular spacing. She has a 6 millimeter (mm) overjet and 5 mm overbite. She is treatment planned for 36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. (1) Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (3) For these reasons, orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal skin fold rashes. 
Treatment: Skin procedure (15830 x 1, 15847 x 1). 
The insurer denied coverage for skin procedure (15830 x 1, 15847 x 1). 
The denial is upheld. 

This is an adult who, according to the letters from the patient's dermatologist, plastic surgeon and bariatric surgeon, has rashes under her pannus that have not responded to medical therapy. Treatment notes are not provided for review. Photos show a female with Grade I pannus and no signs of rashes. 

The medical records do not provide documentation in the form of primary care provider (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. 

According to the American Society of Plastic Surgeons guidelines, "Patients considered for panniculectomy should document the type and duration of symptoms/treatment for panniculitis and photographs should confirm the patient's medical condition." 

Supervised medical management for rashes is not documented in any of the progress notes. Photos do not show rashes. A list of medications used to treat rashes is not provided. In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al., the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed, do not provide sufficient documentation to confirm the failure of medically supervised care. 

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 skin procedure (15830 x 1, 15847 x 1) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

The patient is a male who presented to the emergency department (ED) via Emergency Medical Services (EMS). He had called EMS complaining of chest pain and lightheadedness. By the time the patient was seen in the ED, his chest pain had resolved. His blood pressure was 101/65 mmHg (millimeters of mercury) with a heart rate of 93 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 96 percent (%). An electrocardiogram showed sinus rhythm with left ventricular hypertrophy; there were no acute changes. His high sensitivity troponin I level was minimally elevated at 37 nanograms per liter (ng/L); repeat levels were 38 ng/L and 34 ng/L. His serum creatinine level was 2.67 milligrams per deciliter (mg/dl); his baseline level was not documented. A chest x-ray showed no acute pathology. The patient was treated with aspirin and intravenous fluid and was admitted to the hospital. The patient had left the hospital. The medical necessity for an inpatient admission is at issue.
Based on the documentation provided, an inpatient level of care was not medically necessary. 
This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with no ischemic electrocardiographic changes. His serum troponin level was minimally elevated, with no significant delta troponin. While his creatinine level was elevated, he had a history of chronic kidney disease and his baseline level was not known. He had no significant electrolyte abnormalities. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a school aged male. He presented with acute onset of lower extremity rash with right ankle swelling and some limping. The rash was pruritic, and painful. Exam showed slightly swollen ankle. The patient was afebrile and had normal vital signs. Laboratory evaluation showed non-actionable CBC (complete blood count) differential, mild eosinophilia was noted. Elevated CRP (C-reactive protein) and ESR erythrocyte sedimentation rate were noted. Bedside US (ultrasound) showed cobblestoning without gas, and erythema extending to right lower leg. The patient was started on Ancef and transitioned to oral Keflex the next day to complete a five-day course.

The Inpatient admission was not medically necessary.

The patient did not show signs of sepsis, did not fail outpatient antibiotic treatment and was otherwise well appearing. The patient did not exhibit SIRS (Systemic Inflammatory Response Syndrome), concern for subsequent, future I&D (incision and drainage) need, concern for deeper infection or need for subspecialty consultation. Diagnostic evaluation was inconsistent with septic arthritis or invasive bacterial infection to warrant inpatient management. The patient presented with symptoms suggestive of insect bites, and the ankle swelling could have been managed under observation, as the suspicion was mild trauma due to twisting ankle one day prior.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Blood Pressure, Lightheadedness
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male with submitted diagnoses of elevated blood pressure and lightheadedness and was hospitalized. His past medical history is remarkable for hypertension. He presented to the Emergency Department (ED) for evaluation of elevated blood pressure and feeling lightheaded. His blood pressure check from home was in the 250s. Initial blood pressure check in the emergency department was 233/127. He was in no acute distress. Electrocardiogram (ECG) showed right bundle branch block. Brain computed tomography (CT) demonstrated mild periventricular white matter disease and small old right cerebellar infarct. Laboratory studies revealed non-diagnostic elevated troponin to 27.3, hyperglycemia with glucose 321, hyperglycosuria to 1000 and thrombocytopenia with platelets 111K (thousand). The patient's treatment included intravenous hydralazine and amlodipine 10 milligrams. Subsequent blood pressure readings were 208/104, 185/101, 142/83, and 115/69. Compliance was emphasized for treatment of hypertension and new onset diabetes. The patient left against medical advice. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Current guideline criteria for inpatient admission are not met in this particular case, including hypertensive emergency with evidence of acute and progressing target organ disease such as hypertensive encephalopathy/altered mental status or acute cerebral infarction or Intracranial hemorrhage or myocardial ischemia or infarction or heart failure with pulmonary edema, aortic dissection, new increased creatinine with reduction of more than 50% in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, other significant finding secondary to hypertension, adrenergic or sympathomimetic crisis, such as severe hypertension due to pheochromocytoma crisis, cocaine, phencyclidine, or amphetamine intoxication or clonidine withdrawal or severe hypertension (systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 110 that cannot be controlled (e.g., to systolic blood pressure less than 160 and diastolic less than 100 in adults) by a lower level of care. The care that the patient received for hypertensive urgency and not emergency, like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current standard of care, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: mobility issues
Treatment: home health care
The insurer denied Personal Care Services: 10 Hours per Day, 7 Days per Week (Total of 70 Hours per Week)
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for mobility issues and urinary incontinence. 

The Personal Care Services: 10 Hours per Day, 7 Days per Week (Total of 70 Hours per Week) is medically necessary for this patient.
The patient's care needs are extensive. She requires hands-on assistance with all activities of daily living. The request states that the patient needs additional help in the evenings as she is unable to eat, ambulate, toilet, and transfer to bed without assistance. The task tool recommendation of 61.5 hours per week should be seen as a minimum, and in a patient with care needs who are expected to be continuous and unscheduled throughout the day, additional hours may be medically necessary. The patient and her care team demonstrated that she has needs which extend beyond her current allotment of hours. Therefore, the requested increase to 70 hours per week is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: alcohol abuse
Treatment: inpatient stay
The insurer denied the inpatient stay
the health plan's determination is upheld. 

This is a case of a female patient admitted for diagnosis of alcohol use disorder and withdrawal. She also had rhabdomyolysis secondary to alcohol withdrawal. The patient presented with chief complaint of an alcohol problem. She was noted to drink minimum of five glasses of wine daily but had not drank anything in 10 days. Vital signs demonstrated blood pressure 120/85, pulse 100, temperature 98.1F, respiratory rate 18 and O2 (oxygen) saturation 97%. Physical exam showed no acute distress or altered mental status. White blood cell count was 4.5 with creatinine 0.76. Creatine kinase (CK) total was 1,378. She was treated with librium taper, and ativan for withdrawal seizures as needed. She was treated with B vitamins and a multivitamin. 

An inpatient hospital admission was not medically necessary.
The patient in this case was admitted for alcohol withdrawal but her case was mild. She did not have fever, chills, headache, chest pain, shortness of breath or palpitations. She did not have abdominal pain, nausea or vomiting. She did not have elevated blood pressure. She was not diaphoretic on exam. She did not have a tremor. She did not have any further seizure episode. She was simply treated with a Librium taper and fluid hydration because of the elevated creatine kinase (CK).
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth
Treatment: D5225-Partial Upper Denture
The insurer denied: D5225-Partial Upper Denture
The denial is overturned.

The patient is an adult female. The request is for a partial upper denture. The health plan denied coverage of the request due to her having eight or more posterior teeth in occlusion. The denial is being appealed.

The requested Partial Upper Denture is medically necessary.

The patient has gastric and digestion problems. Her having a partial denture to replace her missing upper teeth and giving her more chewing ability would only benefit her health issues. The partial denture is medically necessary to allow for as complete food mastication as possible.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a history of hypertension, who presented to the hospital with left-sided weakness. On presentation to the hospital, a stroke alert was activated. The patient had a National Institute of Health (NIH) stroke scale of nine. The patient was treated with thrombolytic therapy and transferred to the intensive care unit. A magnetic resonance imaging (MRI) scan of the brain showed an acute infarct in the right corona radiata and basal ganglia. The patient did not have any significant blood vessel stenosis, or occlusion. A repeat CT scan of the head was done after thrombolytic therapy. The patient was treated with antiplatelet therapy and lipid lowering therapy. The patient had poorly controlled hypertension and required a nicardipine drip until oral blood pressure medications The patient was treated for acute sinusitis. The patient's hospital stay was complicated by a fall. He was eventually transferred to acute rehabilitation. At issue is the medical necessity of an inpatient stay.

The patient presented to the hospital with an acute ischemic stroke. The patient had significant right sided weakness. The patient was treated with thrombolytic therapy and required an intensive care stay. Treatment of acute stroke and thrombolytic therapy is the standard of care in the United States. The patient required an intravenous drip of nicardipine for blood pressure management. The patient had complex nursing needs due to treatment of an acute stroke and need for titration of blood pressure medications. The patient had significant neurologic deficit with an initial NIH stroke scale of 9. A stroke scale of 4 or greater is considered to be significant. Due to the degree of disability, the patient required treatment at a rehabilitation facility. All of the care provided is consistent with acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Wall Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who initially presented to the emergency department with concerns for left lower quadrant abdominal pain, fever, and erythema of one week's duration. A chest radiograph was unremarkable. A computed tomography (CT) scan of the abdomen/pelvis revealed left lower quadrant cellulitis with no fluid collection to suggest an abscess and no evidence of necrotizing fasciitis. The patient was admitted to the hospital with an impression of abdominal wall cellulitis. The treatment plan included empiric antibiotics and consultations. Infectious disease consulted and recommended incision and drainage. General surgery consulted and did not recommend incision and drainage on initial inspection. The incision and drainage was then performed at the bedside with local anesthesia. The patient was discharged on oral antibiotics. At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient initially presented with concerns for left lower abdominal wall pain and erythema. Initial evaluation documented the patient as afebrile, hemodynamically stable, with evidence of cellulitis, and leukocytosis. Her glucose was relatively controlled at 135 milligrams per deciliter (mg/dL) and a computed tomography (CT) scan of the abdomen/pelvis did not reveal evidence of an abscess or necrotizing fasciitis. The treatment plan included empiric antibiotics and ultimately a bedside incision and drainage with local anesthesia. The patient was discharged following the procedure. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met. The patient did not have a failure of outpatient therapy, hemoglobin (Hb) A1C (Glycated hemoglobin) greater than (>) 10 percent (%), limb-threatening infection, bacteremia, persistent altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, inability to maintain oral hydration, or severe pain requiring inpatient management. In addition, the patient did not require an associated surgical procedure (ie. abscess drainage, debridement) not amenable to outpatient, emergency department, or observation care or any other condition, treatment, or monitoring requiring inpatient admission.[2]