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

Diagnosis: Vertebrogenic Back Pain
Treatment: 64628 Intracept Procedure
The insurer denied: 64628 Intracept Procedure
The denial is upheld.

The patient is an adult female with chronic low back and lower extremity pain. Past treatments include heat/ice, transforaminal epidural steroid injection, trigger point injection, Advil, Lyrica, and Meloxicam. The pain ranges from five out of ten (5/10) to eight out of ten (8/10). Magnetic resonance imaging (MRI) of the lumbar spine shows lumbar spondylosis, lumbar facet arthropathy, L5-S1 (Lumbosacral) disc bulge, and moderate L4-5 central and 
foraminal stenosis. The request for Intracept was denied as experimental/investigational.

The health plan should not cover the proposed treatment.

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

Diagnosis: Vertebrogenic Back Pain
Treatment: 64628 Intracept Procedure
The insurer denied: 64628 Intracept Procedure
The denial is upheld.

The patient is an adult female who had chronic low back pain. An Intracept procedure has been requested. The procedure was denied as experimental/investigational. Physical therapy has 
been ordered. The patient has failed epidural steroid injections. The patient's physical exam does not reveal any neurological injury.

The health plan should not cover the proposed treatment.

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 adult female who with chronic low back pain. An Intracept procedure has been requested. The procedure was denied as experimental/investigational. Physical therapy has been ordered. The patient has failed epidural steroid injections. The patient's 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 vertebrogenic related chronic low back pain. 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 has not failed conservative treatment; physical therapy has been ordered but there is no documentation on the results. The same applies for facet interventions. According to the attached documentation, facet interventions were recommended, but there is no documentation of the response. Lastly, there is no documentation that sacroiliac joint injections have failed, a common cause of axial 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, sacroiliac injections, do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral ruptured silicone implants
Treatment: Outpatient Services for 14302 Adjacent Tissue Transfer or Rearrangement, any area; each additional 30.0 square centimeters, or part thereof (list separately in addition to code for primary procedure), 15777 Implantation of Biologic implant (e.g., Acellular dermal matrix) for soft tissue reinforcement (e.g., Breast, Trunk) (List separately in addition to code for primary procedure) and 19357 Breast Reconstruction, Immediate or Delayed, with Tissue Expander, including subsequent expansion
The insurer denied: Outpatient Services for 14302 Adjacent Tissue Transfer or Rearrangement, any area; each additional 30.0 square centimeters, or part thereof (list separately in addition to code for primary procedure), 15777 Implantation of Biologic implant (e.g., Acellular dermal matrix) for soft tissue reinforcement (e.g., Breast, Trunk) (List separately in addition to code for primary procedure) and 19357 Breast Reconstruction, Immediate or Delayed, with Tissue Expander, including subsequent expansion
The denial is upheld.

The patient is an adult female with a history of bilateral breast cosmetic augmentation with silicone implants. She complains of tightness due to capsular contracture. Magnetic resonance 
imaging (MRI) showed bilateral ruptured silicone implants. The surgeon performed the following procedures: bilateral pectoralis major muscle flap coverage, bilateral capsulectomy, right breast removal of ruptured silicone implant material, and left breast removal of intact silicone implant. The plan now is for placement of tissue expanders to allow for re-augmentation of her breasts.

The requested health service is not medically necessary.

These procedures were performed to allow for re-augmentation of the patient's breasts. The patient has not had breast cancer and has not had mastectomies. The patient complained of emotional distress due to the contour irregularities in her appeal. The records do not document any health or functional issues due to her breast hypoplasia and contour irregularities. Moreover, the requested treatment is intended to eventually lead to repeat breast augmentation, which may increase the risk for future health problems. Breast augmentation puts the patient at risk for functional problems, including difficulties with mammography, implant infection, implant exposure, anaplastic large cell lymphoma and capsular contracture. According to one study regarding the psychological benefits of breast augmentation, "Significant improvements in body image were found postoperatively and remained throughout the study. Improvements in health-related quality of life, however, were not observed. (1)" The requested surgery will not improve health-related quality of life and will increase the patient's risk for health problems in the future. The patient is likely to derive emotional benefit from the surgery, but her physiologic health will not be improved. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD exacerbation (Chronic obstructive pulmonary disease)
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of hypertension. Presenting complaints were hypoxia. She denied dyspnea or other complaints. She was undergoing alcohol detoxification in a designated area. The physical exam was notable for anxiousness and mild agitation, with a normal pulmonary exam. Radiology was notable for an unremarkable chest x-ray. The patient was admitted to an inpatient level of care for treatment of an acute chronic obstructive pulmonary disease (COPD) exacerbation.
At issue is the medical necessity of an inpatient stay.

The inpatient hospital stay was not medically necessary for this patient.
The patient presented with symptoms of a mild COPD exacerbation, with asymptomatic hypoxia and hypercapnia. There were no abnormalities on pulmonary exam or symptomatic complaints. There was no evidence of respiratory distress, severe symptoms, persistent hypercapnia, need for respiratory support, or hemodynamic instability. The patient was treated with steroids and nebulizers for treatment of a COPD exacerbation. A lower level of care would have been appropriate to monitor the patient for the development of symptoms, continue therapy for COPD exacerbation, and monitor laboratory values.
Appeal type: Medical necessity
Decision: Upheld

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

This adult female was hospitalized for chest pain. She was sent to the emergency department for evaluation of her angina that became worse after her father died. Her exercise stress test last year was positive for ST segment depression and anterior wall ischemia by myocardial perfusion imaging (MPI) and she never followed up for her test results. The patient's vitals were stable. Electrocardiogram (EKG) showed T-wave inversion in leads V4-
6. Treatment included aspirin and cardiac catheterization with coronary angiography without any intervention. There were no procedural complications. The patient was treated medically with 
Imdur and discharged to home after the cardiac catheterization. 
The requested coverage for inpatient hospital admission was denied based on the patient's policy, and the patient is appealing the decision.

The requested health service was not medically necessary.

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

Diagnosis:  Pharyngitis.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

This is a male patient with a history of several days of a sore throat, fever, trismus, and dysphagia who presented to the hospital during the late evening hours after an initial trial of oral Amoxicillin as prescribed by urgent care. A computed tomography (CT) scan of the neck was performed which demonstrated a right peritonsillar abscess. Otolaryngology was subsequently consulted and performed an incision and drainage. The patient was subsequently treated with intravenous hydration, intravenous corticosteroids, and intravenous antibiotics until the symptoms improved sufficiently to be able to tolerate oral antibiotic administration. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient admission was medically necessary for this patient. The patient required inpatient admission to treat a serious, potentially life-threatening condition, with surgical drainage as well as intravenous antibiotics, since the patient had significant trismus and dysphagia requiring initial treatment with intravenous hydration and intravenous antibiotics. He had significant trismus/dysphagia/odynophagia and would not be able to tolerate oral antibiotics. A peritonsillar abscess is a potentially life-threatening condition that requires prompt recognition and treatment. The patient required intravenous antibiotics in this situation until such time as patient's the trismus/dysphagia/odynophagia was sufficiently improved to safely tolerate oral antibiotics. The patient was discharged after receiving intravenous antibiotics and when the patient was deemed medically stable for discharge and could be managed on an outpatient regimen. The patient was evaluated daily to determine the continued need for hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/ Injuries/ Other/ Left-Side Pneumothorax s/p Fall (Bicycling while Intoxicated)
Treatment: 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 has been upheld.

The patient is a male who presented to the emergency department (ED) following a bicycle accident in which he fell after hitting a curb. There was a possible brief loss of consciousness at the scene. At the time of presentation, he was awake and alert with a Glasgow coma score of 15. He complained of left chest pain. He was intoxicated. He was hemodynamically stable with a heart rate of 68 beats per minute (bpm) and an oxygen saturation of 96% (percent). Comorbid health conditions included hypertension. Imaging identified a nondisplaced left 5th rib fracture, a left clavicle fracture, and a left trace pneumothorax.
He was admitted to the hospital. Diet was advanced. The trauma notes document follow up chest x-rays that revealed resolution of the left apical pneumothorax. He remained clinically stable with normal vital signs. Pain management was with oral medications as of the day after presentation. He was discharged from the hospital.

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

The inpatient care was not medically necessary per medical standards or the submitted Milliman Care Guidelines (MCG) for this patient.

The care and treatment provided during this time could have appropriately been rendered with a lower level of care. This patient is a male with medically controlled hypertension. He presented as a hemodynamically stable patient having been involved in a bicycle accident. His injuries included 1 rib fracture, a trace left sided pneumothorax, and a clavicle fracture.

He was clinically stable throughout the period of monitoring as noted in physician and nursing progress notes. He was cleared to ambulate by the physical therapy service and was tolerating a diet with adequate pain management with oral medications. The small left sided pneumothorax resolved without intervention. Based on the documented injuries, patient age, and comorbid health conditions, it was appropriate to monitor this patient with provision of analgesia and follow up imaging. However, this could have been provided with a lower level of care than inpatient status.

Per the submitted MCG (Milliman Care Guidelines), clinical indications for inpatient admission include: hypotension, pneumothorax caused by associated lung disease, traumatic pneumothorax that is moderate, large, or expanding, tension pneumothorax, hypoxemia, altered mental status, significant comorbidity, dyspnea or tachycardia, infection, severe pain, or intervention needed for pneumothorax beyond the observation care time frame. In this case, none of these indications existed to warrant an inpatient designation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the emergency department (ED) complaining of three days of nonexertional chest pain and associated dyspnea. His medical history was remarkable for coronary artery disease, coronary artery bypass graft surgery, chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia and cigarette smoking.  An electrocardiogram showed sinus rhythm with inferolateral ST segment depression that was new compared to prior tracings. His serum troponin level was normal. A chest x-ray showed no acute pathology. The patient was treated with a dose of intravenous labetalol. His chest pain and ST segment depression resolved. Per the emergency department (ED) physician's note, he was admitted to the hospital. Per the nurse's note, the patient eloped. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, for the brief time the patient was hospitalized an inpatient level of care was medically necessary.
This patient, with known coronary artery disease, presented with chest pain at rest. His pain was associated with dynamic electrocardiographic changes. His history and electrocardiographic changes were highly suggestive of unstable angina, a form of acute coronary syndrome. Based on his HEART [history, electrocardiogram (EKG), age, risk factors, troponin] score, his risk for a major adverse cardiac event was 12-16.6 percent (%). He required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain, leukocytosis, pyuria
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This is an adult female patient with diabetes mellitus type II (DM2) and kidney stones. The patient presented with flank pain, leukocytosis, pyuria, and no fever with computed tomography scan findings consistent with pyelonephritis. The patient was admitted to the hospital and treated with antibiotics.

The proposed treatment was not medically necessary.

The patient was afebrile. She was hemodynamically stable. The patient had no urinary tract infection or other findings that would necessitate inpatient hospitalization. She could have been treated with an observation stay. Pyelonephritis does not need to be treated at an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: multiple sclerosis (MS), hypertension (HTN), weakness, decreased mobility, and traumatic medial right ankle wound

Treatment: durable medical equipment E0261 x 1, E0185 x 1 (gel mattress pad and semi electric hospital bed)

The insurer denied coverage for durable medical equipment E0261 x 1, E0185 x 1 (gel mattress pad and semi electric hospital bed)

The denial is upheld.

 
The patient has been diagnosed with multiple sclerosis (MS), hypertension (HTN), weakness, decreased mobility, and traumatic medial right ankle wound. The request is for durable medical equipment (DME) in the form of gel mattress pad and semi electric hospital bed (E0261 x 1, E0185 x 1).

The patient is able to move and position herself and does not need pressure relieving equipment. The request is excessive and does not meet medical necessity criteria. As such, the denial is upheld.

Per Levinson, R., Salas, L., & Zanca, J. M. (2023), "Although many studies have demonstrated the benefits of specific pressure-relieving surface, there is no consensus on the optimal type of a support surface. While skin protection is a top priority in choosing a support surface, other factors are also important. Westcott and Welding studied bed use among patients who transitioned back into the community. Their findings revealed that health professionals were prescribing mattresses that did not meet the needs of patients well, and should consider aspects such as mobility, comfort, microclimate, and patient's choice when ordering a mattress. In some cases, mattresses were downgraded to less dynamic surfaces or to standard beds, and individuals reported better comfort, mobility, sleep, and/or ability to sleep with a partner after the downgrade."

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 durable medical equipment E0261 x 1, E0185 x 1 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

This is a female patient who was admitted to the hospital with a history of epilepsy. She had not had a seizure for 2 years prior to admission. She has developmental delay and speech impairment. She attends a special school, where she receives speech and physical therapy.
The patient takes the anticonvulsant oxcarbazepine to prevent seizures. There is discrepancy in the notes as to whether or not she occasionally misses doses. She had an episode of non-bloody, non-bilious vomiting on the day of admission. Her oxcarbazepine blood level in the emergency room was subtherapeutic at 4 micrograms per milliliter (mcg/ml) (therapeutic range 10-25 mcg/ml). On the day of admission, the patient had a witnessed generalized tonic-clonic seizure lasting 10 minutes, followed by a 1020-minute postictal period. Apart from developmental delay and hypotonia, her examination was reported to be normal. Laboratory testing showed a mildly elevated blood glucose at 113 milligrams per deciliter (mg/dl), and a subtherapeutic oxcarbazepine level as described above. She was given intravenous lorazepam and ondansetron to prevent vomiting. After a telephone consultation with a child neurologist the initial plan was to observe her in the emergency room then discharge to home, but she had a further episode of non-bloody, non-bilious vomiting in the emergency room, which prompted inpatient admission. Oxcarbazepine was given orally, and she was later discharged to home, having had no further vomiting.
At issue in this review is whether inpatient admission was medically necessary.

The requested health service/treatment of inpatient stay was medically necessary for this patient.

The patient has a history of epilepsy; although she was on an anticonvulsant, oxcarbazepine, there was a history of possible non-adherence to taking the medication. She had vomiting prior to admission and had further vomiting in the emergency room. Her oxcarbazepine level was subtherapeutic at 4 mcg/ml (therapeutic range 10-25 mcg/ml). This means that she had insufficient oxcarbazepine in her body to prevent seizures. Oxcarbazepine is a medication that can only be given by mouth [2]; a dose could not be given intravenously to "load" her in the emergency room. She was at risk of seizure clusters and status epilepticus [3]; it was appropriate and medically necessary to admit her to the hospital to ensure that she had no further seizures, and that her vomiting subsided and she was able to take oxcarbazepine by mouth.