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

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is upheld.

The patient is an elderly male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as 
experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy). MRI (magnetic resonance imaging) shows Modic changes, but also severe spinal stenosis. PE (physical examination) reveals no neurologic deficit.

The health plan should not cover the Intracept procedure.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an elderly male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy). MRI (magnetic resonance imaging) shows Modic changes, but also severe spinal stenosis. PE (physical examination) reveals no neurologic deficit. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new 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 has been shown effective in RCT (randomized controlled trials) with 5-year results. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient in this case has not failed or attempted facet, or sacroiliac joint injections, which are common causes of axial low back pain. In addition, the patient has severe spinal stenosis that is not evidenced to have been addressed. This is can also be a cause of low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives, facet interventions and sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld.

This woman presented to the emergency department (ED) complaining of one week of intermittent non-exertional left-sided chest pain and headache. Her medical history was remarkable for type 2 diabetes, hyperlipidemia and seizure disorder. She had a cardiac catheterization in that showed normal coronary arteries. In the ED, her blood pressure was 141/86 with a heart rate of 63 beats/minute. Her room air oxygen saturation was 100% (percent). Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm at 56 beats/minute. There was inferolateral T wave inversion. There were no acute changes, and the tracing was similar to prior tracings. Her troponin level was normal when measured twice. Chest X-ray showed mild cardiomegaly. The patient was treated with ibuprofen and acetaminophen and was admitted to the hospital.

The inpatient hospital admission was not medically necessary.

This woman presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Cardiac catheterization a year prior had shown no significant coronary artery disease. While her myocardial perfusion scan was abnormal, there were no high-risk findings. She 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 both safe and effective and is in accordance with current guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain/dizziness
treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

This case involves a woman with asthma, who was admitted to the hospital with dizziness and chest pain for three days. They are both exertional, and relieved at rest. The chest pain was described as sharp, radiating down the left arm with diaphoresis, shortness of breath, and nausea. She furthermore complains of heat intolerance, hair loss, and a weight change of 10 pounds within a month. Finally, she complained of nausea, vomiting, and abdominal pain for four days.

The inpatient hospital admission was not medically necessary.

Based on the provided documentation, this is a chest pain rule-out admission typically performed at a lower level of care. There were no electrocardiogram (EKG) changes, unstable vital signs, or elevated troponins to suggest an acute coronary syndrome. The heart score (history, EKG, age, risk factors, initial troponin) is 3, based on age, EKG, cardiac troponin risk factors. The echocardiogram and stress test did not reveal significant cardiac pathology to warrant further invasive cardiac testing and treatment.

From a gastrointestinal (GI) standpoint, the patient's marijuana use was identified as a problem for nausea and vomiting; the work-up identified normal LFTs (liver function tests), lipase, and gallbladder imaging with an ultrasound. Therefore, there were no life-threatening conditions that required conversion to inpatient status for advanced treatments that could not be delivered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lower quadrant pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

This patient is an adult female with hypothyroidism, hypertension, diabetes mellitus, uterine embolization, and Cesarean section who presented to the emergency department with right lower quadrant (RLQ) pain for three days. The pain was exacerbated when she urinated. The patient had nausea. The patient was afebrile and had leukocytosis to 14,000. 
Computed tomography (CT) scan of the abdomen / pelvis showed sigmoid diverticulitis without perforation or abscess. The patient was treated with intravenous fluids. The patient was started on levofloxacin 750milligrams (mg) intravenous (IV) every 24 hours (q24h) and metronidazole 500 milligrams intravenous every 8 hours. The patient was also treated with Protonix 40 milligrams daily and clear liquid diet / advanced as tolerated. Levofloxacin was discontinued due to possible allergy. 

The requested health service was not medically necessary. 

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists after observation care; and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on an ambulatory basis. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth Hormone Deficiency
Treatment: Skytrofa Injection 11MG (milligrams)
The insurer denied: Skytrofa Injection 11MG (milligrams)
The denial is overturned.

The patient is an adolescent male. He is diagnosed with growth hormone deficiency (GHD). This request is for Skytrofa (lonapegsomatropin-tcgd). As noted in the letter, the patient has a low intolerance to needles and injections. His response was frightening and anxiety provoking for both him and caregivers; when he is given an injection, he becomes clammy, nauseous, and faint. The patient's growth hormone stimulation test with clonidine and glucagon peaked at 4.8. During his growth hormone stimulation testing process, there was a lab error that resulted in him having to go through a third growth hormone stimulation test. This required additional lab work and insertion of an intravenous catheter. He became increasingly anxious with each additional lab draw/needle stick. He was visibly upset, faint, nauseous, and clammy. He was resistant to even starting the treatment; however, agreed to start a therapy that was weekly versus daily. He was then started on the Fast Start Program with Skytrofa.

The requested health service is medically necessary.

The requested medication has been shown to be safe and effective for the treatment of growth hormone deficiency (5, 6). The study using the medication shows that the medication is clinically equivalent to daily injections of growth hormone in terms of efficacy and safety. The study showed a slight advantage of the Skytrofa over daily somatropin but only went for one year and did not show improved final height. It has the advantage of being a weekly medication. Other than the convenience of weekly administration, the requested medication is not superior to daily growth hormone.
The patient suffers from severe anxiety accompanied by fainting and nausea and becoming clammy because of the daily injections of the growth hormones. Skytrofa will provide him with a once weekly injection only and he agreed to trying the once weekly injection and tolerating it. The request meets the standard of care and is, therefore, medically necessary for this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lightheadedness and near syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult who presented to the hospital with lightheadedness and near syncope.  Past medical history was significant for diabetes mellitus and hypertension. On arrival to the hospital vital signs were stable: Blood Pressure 142/88 and pulse 74 beats per minute. Physical exam revealed no significant abnormality. Serum blood tests revealed a Blood Urea Nitrogen (BUN) of 14 and Creatinine of 0.5 milligrams (mg)/deciliter (dl).  Cardiac enzymes were not elevated (troponin < [less then]5.0).  Electrocardiogram (ECG) revealed normal sinus rhythm with normal intervals and no evidence of ST or T (cardiac rhythm) wave abnormality.  The patient was admitted to the hospital for further testing.  She was treated with intravenous (IV) fluids and ultimately, telemetry monitoring which revealed no sustained arrhythmia.  Echocardiogram revealed a normal left ventricle ejection fraction (LVEF) (60-65% [percent]) and no significant valvular abnormalities. Carotid duplex demonstrated no significant obstruction.  Cardiology evaluation was unrevealing and the patient was discharged.

Physical examination and serum blood testing revealed no major abnormalities.  Echocardiography revealed a structurally normal heart with a normal left ventricular ejection fraction and no rhythm abnormality was noted on electrocardiogram (ECG) or telemetry. This patient falls into a low to intermediate risk group for syncope.  According to American Heart Association/ American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS) guidelines such patients should be managed utilizing a structured emergency department (ED) observational protocol (Reference 1).  In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2).  In this case, the patient had a normal echocardiogram and a normal 12 lead electrocardiogram (ECG). Acute inpatient admission was not medically necessary for this patient.

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: Upheld

Diagnosis:  Osteoarthritis, hypertension, chronic pain, cardiovascular disease, and para esophageal hernia.
Treatment: Increase Personal Care Assistance Services to 40 Hours per Week.
The insurer denied an increase in Personal Care Assistance Services to 40 Hours per Week.
The denial is upheld.

The patient is an elderly male who has medical conditions that include osteoarthritis, hypertension, chronic pain, cardiovascular disease, and para esophageal hernia. The denial of an increase in personal care assistance services to 40 hours per week is being appealed. The patient currently has 24 hours of service. 
Uniform Assessment System evaluation completed 4 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medication, bathing, personal hygiene, and dressing; limited assistance with walking and locomotion; and independent with toileting, bed mobility, and eating. The patient is a continent of bowel and bladder. A letter from the Provider notes the patient needs assistance with activities of daily living due to chronic conditions. He has no informal support.

The proposed treatment is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals including assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. The denial of an increase in personal care assistance services to 40 hours per week is being appealed. He currently has 24 hours of service. Uniform Assessment System (UAS) evaluation completed 4 months ago shows the patient is independent with toileting, bed mobility, and eating. He is continent of bowel and bladder. An appeal letter states the patient needs increased hours due to chronic conditions. The information provided does not support that the patient has functional needs requiring increased personal care assistance services of 40 hours per week. Personal care assistance services are not indicated for the management of chronic conditions or when no tasks are being performed. The approved personal care assistance services 24 hours per week are appropriate to meet this patient's needs for assistance with activities of daily living. The proposed personal care assistance services 40 hours per week are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/ Musculoskeletal
Physical Therapy

Diagnosis: Other- Mobility issues 
Treatment: Physical therapy 

The health plan denied: Physical therapy 
The determination is: Upheld 


The patient is a male diagnosed with mobility issues. His medical records indicate that additional physical therapy was requested but was denied. The provider asked for more therapy, but records did not show the patient's current status and goals, specific goals to improve on, whether the patient was making progress towards listed goals, or progress being measured with special tests and tools.
According to the records provided, the patient had a history of a right foot ulcer, a left below-the- knee amputation, anxiety, asthma, depression, deep vein thrombosis, gastroesophageal reflux disease (GERD), hyperlipidemia, obesity, osteomyelitis, osteoporosis, peripheral vascular disease, plantar fasciitis, sleep apnea, substance abuse, and venous insufficiency. It was noted that the patient presented to physical therapy status post below-the-knee amputation of the left lower extremity, again with right ulcer debridement and resection of the right fifth metatarsophalangeal joint, and finally with right foot pain and decreased functional mobility. It was noted that the patient had not walked since the surgery. A physical therapy note indicated the patient's functional scale was 17/50 and the patient reportedly had slight positive gains, although a therapy note on a subsequent visit indicated functional scale was 14/50. The patient was able to ambulate 50 feet with a rolling walker and gait belt by the therapist and there was a goal to ambulate 50 feet with a rolling walker with minimal assistance.
At issue is the medical necessity of the physical therapy.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of physical therapy is not medically necessary for this patient. Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home physical therapy (PT). Abnormality of gait: 9-48 visits over 8-16 weeks (based on specific condition)."
The patient is noted to have a history of a below-the-knee amputation of the left lower extremity, right ulcer debridement and resection of the right fifth metatarsophalangeal joint with right foot pain, and decreased functional mobility and endurance with ambulation. The patient has not walked since surgery. There were minimal improvements noted with a functional scale of 14/50 and prior functional scale of 17/50. It was noted that pain had improved to 4/10 in the left stump but there were no specific therapeutic goals outlined at that time or documentation that the patient was progressing towards achievement of those goals. Therefore, additional physical therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, dizziness, hypothyroidism, coronary artery disease, and arthritis
Treatment: Personal Care Aide Level 2 to 168 Hours per Week (12 Hours x 2 x 7 Days - Split Shift)
The insurer denied: Personal Care Aide Level 2 to 168 Hours per Week (12 Hours x 2 x 7 Days - Split Shift)
The denial is overturned.

This elderly female patient has medical conditions that include dementia, hypertension, dizziness, hypothyroidism, coronary artery disease, and arthritis. She lives alone. Denial of 
increase of personal care aide to 168 hours per week (12 hours x 2 x 7 days - split shift) is being appealed. The health plan approved 84 hours per week. Uniform Assessment System evaluation completed six months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, and lower body dressing; extensive assistance with managing finances and medications, phone use, personal hygiene, upper body dressing, walking, locomotion, and toilet transfer; limited assistance with toilet use, bed mobility; and independent with eating. Her activities of daily living status have declined over 90 days. She is continent of bowel and bladder.
A Night Time needs document notes the patient usually get up two to three times around 2 AM, 4 AM, and 6 AM and needs assistance to the bathroom.

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. Continuous 
or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. Denial of increase of personal care aide to 168 hours per week (12 hours x 2 x 7 days - split shift) is being appealed. The health plan approved 84 hours per week. The health plan denied the request because the patient does not have continuous nighttime needs. However, Uniform Assessment System evaluation completed six months ago shows the patient requires with all activities of daily living, except eating. The Night Time needs document notes the patient usually get up two to three times during the night and needs assistance with toileting. The appeal statement supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift based on her nighttime toileting needs. The proposed increase of personal care aide to 168 hours per week (12 hours x 2 x 7 days - split shift) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/ Musculoskeletal/Unilateral Primary Osteoarthritis, Right Knee; s/p Total Knee Replacement
Inpatient Hospital/Inpatient Hospital Admission
The health plan has denied the requested treatment, inpatient hospital admission, as not medically necessary. The health plan's determination is upheld.

The patient is a woman with a history of osteoarthritis (status/post (s/p) left total knee replacement), fatty liver, anxiety, and frequent urinary tract infections (UTI). She was admitted for a right total knee replacement. The patient's vital signs were unremarkable, and the physical exam was otherwise non-contributory. The patient's laboratory studies were essentially normal. She underwent a right total knee replacement procedure. The procedure went well and was without complications. The remainder of the stay was clinically uneventful, and the patient was discharged.

At issue is the medical necessity for an inpatient hospital admission.
The health plan's determination of medical necessity is upheld, in whole.

The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam or laboratory studies of an imminently life-threatening condition that required the patient to remain as an inpatient for an additional two days after her surgery. There was no hemodynamic instability, mental status changes, or severe metabolic disarray. The surgery went well, was without complications, and the procedure and immediate postoperative care did not require acute inpatient admission. The services provided - physical therapy, oral medication - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.