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

Diagnosis: Dementia
Treatment: Home health care
The insurer denied Personal Care Services: 24 Hours a Day, 7 Days a Week (Split-Shift)
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, hyperlipidemia, dementia, osteoarthritis, incontinence of bladder, and incontinence of bowel who had been assigned PCA (personal care assistant) services. There was a request to increase PCA services and the patient underwent a video assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, bathing, dressing lower body, locomotion, and toilet use while maximum assistance with tasks of meal preparation, phone use, transportation, personal hygiene, dressing upper body, and bed mobility. The patient was assessed at extensive assistance with tasks of managing medication and eating while it was noted the activities did not occur for walking and transfer toilet. 

Personal Care Services: 24 Hours a Day, 7 Days a Week (Split-Shift) is medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCA (personal care assistant) services. Specifically, the provider documented the need for turning and repositioning every 2 hours to prevent skin breakdown. The patient has documented bladder and bowel incontinence with need for maximum assistance with bed mobility. In addition, the patient requires total assistance with tasks of toilet use and incontinence cares. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient is unable to call 911 for help due to dementia. The patient's care needs in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

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

This is a female patient with a history of ureteral strictures, tobacco abuse, obesity, and diabetes, who presented to the emergency room with dizziness and weakness.  A chest x-ray, computed tomography (CT) scan of the abdomen/pelvis and electrocardiogram (EKG) were unremarkable. The patient was given intravenous (IV) fluids and magnesium and admitted. The patient reported that she had recently had a scan of her chest that showed granulomas concerning for sarcoidosis. Cardiology was consulted and recommended an echocardiogram and believed her syncopal symptoms were secondary to volume depletion. Psychiatry was consulted regarding the management of her Suboxone. Nephrology was consulted for hypercalcemia which they believed was secondary to underlying sarcoidosis and started the patient on prednisone. A recent biopsy of a lymph node was obtained by nephrology that showed non-necrotizing granulomas. The patient no longer felt dizzy and was discharged. At issue is the medical necessity of an inpatient stay.

Admission was medically necessary at the acute inpatient level of care. The patient presented with dizziness, hypercalcemia and an acute kidney injury. Hypercalcemia is defined as a serum calcium 10.5-11.9 milligrams per deciliter (mg/dL), moderate hypercalcemia 12-13.9 mg/dL and hypercalcemia crisis is defined as greater than (>) 14 milligrams per deciliter (mg/dL) (Sidiq et al 2022). The patient had a calcium of 12.1 on presentation to the emergency room (ER). Hypercalcemia can lead to life threatening complications such as acute kidney injury (present in this patient), digestive issues, neurological impairment (present in this patient with dizziness), hypertension (1). The patient had recently been worked up for sarcoidosis in which hypercalcemia is part of the disease process. Treatment of hypercalcemia involves fluid hydration and potentially medication management if response is not seen with fluids. Concurrently, the patient presented with an acute kidney injury (creatinine (Cr). 1.78). Only about 50 percent (%) of patients who present with an acute kidney injury have recovery of renal function to baseline (2). Further, not recovering kidney function to baseline is associated with adverse outcomes, therefore monitoring renal function is absolutely critical (3,4). To evaluate and treat hypercalcemia in the setting of possible sarcoidosis and assess if cardiac sarcoid is involved (i.e. potentially lethal process), hospitalization for this work-up would be expected to last greater than (>) 2 midnights due to the complex nature of this case, thus further specifying the need for the impatient level of care. (Centers for Medicare and Medicaid Services (CMS) guidelines).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The determination is upheld. 

This is a male patient with a history of coronary artery disease (CAD) and diabetes. His presenting complaints were progressive dyspnea on exertion and lower extremity edema. The physical exam was notable for 2 plus (+) bilateral edema. Lab results were notable for hematocrit 29.8, blood urea nitrogen (BUN) 32, glucose 239, elevated troponin, and elevated brain (or B-type) natriuretic peptide (BNP). Radiology was notable for a computed tomography (CT) scan of the chest showing multifocal pneumonia along with oropharyngeal narrowing (reported as outpatient). The patient was admitted to an inpatient level of care for treatment of pneumonia. 
At issue is the medical necessity of an inpatient stay. 
The inpatient hospital admission was medically necessary. 
The patient presented with a high-risk pneumonia (Pneumonia Severity Index class IV) evidenced by an elevated blood urea nitrogen (BUN), glucose, and low hematocrit, and with significant hypoxia and dyspnea. An inpatient level of care would have been most appropriate to monitor the patient closely, and provide therapies and support for treatment of his pneumonia. A lower level of care would not have been appropriate to provide this support.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Substance abuse residential
The insurer denied Inpatient Chemical Dependency Rehabilitation Services. The health plan's determination is upheld. 

The patient is an adult male who was admitted to inpatient rehabilitation substance use disorder treatment of stimulant (cocaine), alcohol, hallucinogen (hallucinogens (phencyclidine) (PCP)) and cannabis (marijuana) use disorders. The patient was using $(dollar)50 worth of cocaine, one bag of marijuana, and use of one and one-half pints of alcohol daily, as well as use of PCP. The patient was also tobacco dependent with light use. 

Inpatient Chemical Dependency Rehabilitation Services were not medically necessary for this patient.
The inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with clinically appropriate structure, monitoring and sober supports. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment.
Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment through Discharge. Thus, the requested inpatient substance use disorder rehabilitation services was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient presented with abdominal pain and vomiting. She was having heavy menstrual bleeding. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The hemoglobin was 11.3 and on repeat was 12.3. The initial potassium was 2.9 but by the time of admission was 3.7. There was mild elevation of the liver enzymes. It was felt that her symptoms were related to cannabinoid use. 

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

Clinical indications for admission for Vomiting MCG M-370 include having a severe metabolic derangement, a severe electrolyte abnormality, stage 3 kidney injury, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had abdominal pain and vomiting likely secondary to cannabinoid use. Intravenous (IV) hydration and antiemetics could have been given in the emergency room (ER) as an outpatient. The potassium was able to be corrected by the time of admission. She had vaginal bleeding, but her hemoglobin was stable. She did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Vomiting. She could have been managed with observation 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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Unspecified infectious disease
Treatment: Test (primary Immune deficiency panel)
The insurer denied: Test (primary Immune deficiency panel)
The denial is overturned.

The patient is an adult male with a diagnosis of unspecified infectious disease. He has a history of recurrent fungal infection. In 2016, he developed a sore throat that has been intermittent and was later diagnosed with candidiasis. He has had oral candidiasis for 4 years and has developed esophageal strictures and inflammation with difficulty swallowing solid food. He 
has dystrophic nails and fungal infection of the toenails. He has tried nystatin and systemic fluconazole, which initially helped, but no longer helps. Topical and systemic steroids were tried and helped temporarily. He has developed psoriasis. A skin test for candidiasis was strongly positive. He has had a weight loss of over 40 pounds.

The requested primary immune deficiency panel is medically necessary.

This is a patient with a significant history of fungal infection that is affecting his daily life, causing a weight loss of over 40 pounds and giving him difficulty with swallowing foods. Appropriate diagnosis is needed for an appropriate treatment plan. Fungal infections can be due to immunodeficiencies and must be ruled out with testing. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Side Numbness and Tingling
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with multiple medical problems. She presented with left-sided paresthesia of two hours' duration. The patient's exam revealed no focal deficit. Computed tomography (CT) showed no acute pathology. Magnetic resonance imaging (MRI) showed suprasellar mass, and neurosurgery was consulted. MRI (magnetic resonance imaging) of the sella turcica was ordered. The patient was not deemed to be a surgical candidate. Labs were ordered, and the patient was eventually discharged with follow-up.

The Inpatient Hospital Admission was medically necessary.

The patient was found to have a hemorrhagic mass in the pituitary after stroke workup. Additional testing and labs were performed, and consultation to neurosurgery and neurology were required, as this patient had concerning findings that were possibly needing surgery. The patient was eventually deemed safe for discharge with follow-up after being found to be stable. In this setting, the entire hospitalization was medically necessary and appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Thermal destruction of intraosseous basivertebral nerve
The insurer denied thermal destruction of intraosseous basivertebral nerve
The determination is upheld.

This is a female patient diagnosed with vertebrogenic low back pain. The patient was previously recommended to undergo an interosseous basivertebral nerve ablation (Intracept) procedure. The patient has a history of low back pain. She has had multiple treatments including heat/ice, lumbar epidural steroid injections, massage therapy, medication management, physical therapy, radiofrequency ablation, and trigger point injections. The pain is impacting activities of daily living and ranges from 7-9/10. Nothing has provided significant or sustained relief. The provider reports the patient had a magnetic resonance imaging (MRI) scan performed showing Modic type II changes at disc spaces lumbar (L) 3- L4, L4- L5 and L5-sacral (S) 1 and the provider believes that this is the source of the patient's chronic back pain.
At issue is whether thermal destruction of intraosseous basivertebral nerve is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment of intraosseous basivertebral nerve ablation procedure 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 is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve (BVN) ablation). It should be noted however that the MRI provided does not mention Modic changes or degenerative endplate changes. There are a lack of high-quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Thermal destruction of intraosseous basivertebral nerve
The insurer denied thermal destruction of intraosseous basivertebral nerve.
The determination is upheld.

This is a female patient with a chronic history of low back pain. Prior treatments have included lumbar injections, medications, physical therapy, as well as massage therapy. The pain ranges from 7-9 out of 10.
The pain significantly impacts activities of daily living (ADLs). Magnetic resonance imaging (MRI)of the lumbar spine was with reported Modic type 2 changes lumbar (L) 3-4, L4-5 and L5-sacral (S) 1. At issue is whether thermal destruction of intraosseous basivertebral nerve is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment thermal destruction of intraosseous basivertebral nerve 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 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 lack of data to recommend this procedure as treatment modality. In general, there is 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 Thermal destruction of intraosseous basivertebral nerve 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: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Thermal destruction of intraosseous basivertebral nerve
The insurer denied thermal destruction of intraosseous basivertebral nerve.
The determination is upheld.

This a female patient diagnosed with vertebrogenic low back pain. Records provided noted that the patient was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the health plan.
The provider states the patient has had low back pain for over one year and has had multiple treatments including heat, ice, lumbar epidural steroid injections, massage therapy, medication management, physical therapy, radiofrequency ablations and trigger point injections. Medications have included Naproxen. The pain is impacting activities of daily living such as lying down, sitting and standing. Nothing has provided sustained relief. The pain ranges from 7-9/10. She had a magnetic resonance imaging (MRI) performed and the provider states that the MRI demonstrated Modic type II changes at disc spaces lumbar (L)3-L4, L4-L5 and L5-sacral (S) 1 and the provider believes this is the source of the patient's chronic back pain. 
At issue is whether thermal destruction of intraosseous basi-vertebral nerve is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No, the proposed health service or treatment Intraosseous Basivertebral Nerve (BVN) Ablation Procedure 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 chronic back pain present for more than one year with failed conservative treatment, medications and injections. The MRI shows degenerative disc disease with neural foraminal narrowing and encroachment of the right transiting S-1 nerve roots as well as bilateral facet joint arthrosis at L5 - S1. The provider believes the patient's back pain is coming from Modic changes, although this was not mentioned by the radiologist.
This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis

Treatment: Hyaluronan Injections (procedure code J7324)

The insurer denied coverage for Hyaluronan Injections (procedure code J7324).

The denial is overturned.

This is a patient with chronic bilateral knee pain and osteoarthritis (OA).  Treatment included a series of Hyaluronan Injections (procedure code J7324) knee injections (every 6 months); the continuation of which has been denied by the insurer, leading to an external review.  

Visco-supplementation (i.e., Hyaluronan injection) is a therapeutic modality for the treatment of osteoarthritis based on the physiologic importance of hyaluronan in synovial joints.  Its therapeutic goal is to restore the visco-elasticity of synovial hyaluronan, thereby decreasing pain, improving mobility and restoring the natural protective functions of hyaluronan in the joint.  There is a lack of reliable evidence that any one brand of viscosupplement is superior to other brands for medically necessary indications. However, visco-supplementation has been shown as a safe and effective treatment for this patient's bilateral knee osteoarthritis with beneficial effects for pain, flexibility (decreased stiffness) and function.

As discussed in a guideline from the American College of Rheumatology "In clinical practice, the choice to use hyaluronic acid injections in the knee OA patient who has had an inadequate response to nonpharmacologic therapies, topical and oral non-steroidal anti-inflammatory drugs (NSAIDs), and intraarticular steroids may be viewed more favorably than offering no intervention, particularly given the impact of the contextual effects of intraarticular hyaluronic acid injections (38). The conditional recommendation against is consistent with the use of hyaluronic acid injections, in the context of shared decision-making that recognizes the limited evidence of benefit of this treatment, when other alternatives have been exhausted or failed to provide satisfactory benefit."

From a physical medicine & rehabilitation/pain medicine perspective, as well as with reasonable medical certainty, the requested Hyaluronan Injections (procedure code J7324) is medically necessary.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Hyaluronan Injections (procedure code J7324) is substantiated.