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

Diagnosis:  Right Hip Arthritis.
Treatment: Arthroplasty Hip (Total Hip Replacement) Surgery.

The insurer denied Arthroplasty Hip (Total Hip Replacement) Surgery.  The health plan's determination is upheld. 

This is a female diagnosed with right hip arthritis. A clinical progress note documents that the patient presented regarding right hip pain with activity. There is a body mass index (BMI) of 29.5. The examination noted reduced painful motion and positive FADIR (flexion, adduction, internal rotation). There is a diagnosis of arteriovenous malformations (AVM) of the right hip.

Arthroplasty Hip (Total Hip Replacement) Surgery is not medically necessary.

The current medical literature supports hip arthroplasty for end stage hip arthritis not improved with conservative treatments. In this circumstance, the patient is noted to have right hip pain not improved with activity modification, anti-inflammatories, analgesics, and home exercises. An excerpt report documented mild degenerative changes with no joint space narrowing and acetabular osteophytes. A right hip magnetic resonance imaging (MRI) documented a small zone of avascular necrosis with no subchondral collapse and mild degenerative changes. The provider recommended arthroplasty. There is not documentation of end-stage hip arthritis to support arthroplasty. Imaging demonstrates only mild arthritic changes. Additionally, there is no evidence of subchondral collapse associated with avascular necrosis. As noted in the below article in StatPearls, core decompression is the standard treatment for early avascular necrosis with no evidence of subchondral collapse.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Refractory Seizures.
Treatment: Laser Radiation Therapy to the Brain.

The insurer denied Laser Radiation Therapy to the Brain.  The denial is overturned.

This is a school aged child who carries a diagnosis of intractable epilepsy, demonstrably refractory to medical treatment, for which authorization of coverage for ablative treatment with Laser Interstitial Thermal Treatment (LITT) is sought. Prior denial was made on the grounds of ambiguity of the indication for treatment and insufficient trials of preferred formulary alternative treatments. 

The health plan should cover the proposed treatment. 

There is a clear rationale for the choice of treatment and the utility over a gross resection that is grounded in best evidence and represents a best practice approach for this patient's particular and unique presentation of medically refractory intractable epilepsy. The patient demonstrates a complex congenital etiology resulting in cortical dysfunction in highly epileptogenic regions of the brain. A key difference between this patient and the studies that compared selective ablation to traditional open resection did such comparisons in patient with localization related epilepsy of a variety of etiologies including mesial temporal sclerosis, neoplastic processes, and vascular malformations. Taken in sum total, the advantages of LITT (Laser Interstitial Thermal Treatment) are diluted to the extent that the coarse conclusion suggested non-inferiority and unclear, if any benefit to the approach. In highly selected patient groups where precision cortical monitoring guides treatment, and there is intercalation of lesional epileptogenic foci in regions of eloquent cortex, there is a clear benefit to guided therapies. While studies that provide the evidence for these treatments suffer from methodological constraints arising from statistical and ethical limitations, this is a similar pattern to other rare diseases. Although still in active investigations, these treatments are consistent disease models and demonstrate consistently positive outcomes to the extent they become standard of care well ahead of FDA (Food Drug Administration) -approval. In this case, the patient presents with clinical criteria for Lennox-Gastaut syndrome without a genetic channelopathy, demonstrating lead electrographic lesional boundaries amenable to this approach.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Refractory Seizures.
Treatment: Laser Radiation Therapy to the Brain.

The insurer denied Laser Radiation Therapy to the Brain.  The denial is upheld.

The patient is a school aged male with medically refractory seizure disorder. The provider has requested laser interstitial thermal therapy. 

The health plan should not cover the proposed treatment.

There are no high-quality clinical trials comparing the efficacy of laser interstitial thermal therapy (LITT) to any other treatment option. However, systematic review and meta-analysis of surgical strategies for drug-resistant epilepsy found that surgical resection was associated with better seizure outcomes compared with radiofrequency ablation (RFA) or laser interstitial thermal therapy (Kohlhase et al.). Therefore, interstitial thermal therapy is not considered more beneficial than any other treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Refractory Seizures.
Treatment: Laser Radiation Therapy to the Brain.

The insurer denied Laser Radiation Therapy to the Brain.  The denial is overturned.

The patient is a school aged boy with medically refractory localization related epilepsy who has tried multiple anti-seizure medications, he underwent stereotactic EEG (electroencephalogram) which localized the epileptogenic focus. His epileptologist and neurosurgeon recommend laser ablation (Laser Interstitial Thermal Therapy) to decrease the seizure burden. The request for coverage was denied due to not meeting plan requirements for experimental and investigational treatments.

The health plan should cover the proposed treatment. 

Epilepsy surgery including laser interstitial thermal therapy is an accepted treatment for medically refractory localization related epilepsy. The corpus of peer-reviewed clinical evidence demonstrates benefit of MRI (magnetic resonance imaging)-guided laser ablation over craniotomy for resection of epileptic focus: decreased mobility, ability access sites that are not amenable to open surgery, shorter recovery time and shorter hospital stay. (Wu 2019, Wu).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Monoplegia of Upper Limb (following cerebral infarction). 
Treatment: 64568 Open Implantation of Cranial Nerve, C1827 Generator Neurostimulator (implantable) nonchargeable, with implantable stimulation lead and external paired stimulation controller. 
The insurer denied 64568 Open Implantation of Cranial Nerve, C1827 Generator Neurostimulator (implantable) nonchargeable, with implantable stimulation lead and external paired stimulation controller. 
The denial is overturned.

The member is an adult male with history of right cerebrovascular accident as a result of a right internal carotid artery dissection leading to a profound left hemiparesis. The request is for a paired Vagus Nerve Stimulation (VNS) to improved functionality and improved use of the arm along with augmentation of rehabilitation and prevent further deterioration. He has failed conservative efforts in rehabilitation with his activities of daily living (ADLS) severely affected. The reason for denial was lack of evidence of effectiveness of the procedure and that it is experimental and investigational under the health plan. 

The health plan should cover the proposed treatment. 

In this case, the Vagus Nerve Stimulation (VNS) is medically appropriate in a patient with monoplegia secondary to cerebrovascular accident (CVA) who has failed other conservative measures. Systematic review and randomized controlled trials in peer-review journals confirmed the effectiveness of Vagus Nerve Stimulation in improving activities of daily living (ADLs)/functionality and therefore that it is not experimental or investigational. 
According to Ahmed, I et al, in a systematic review with meta-analysis of randomized controlled trial: "Moderate- to high-quality evidence suggests that tVNS and anodal tDCS were effective in improving upper limb motor function in both acute/subacute and chronic stroke. In addition to tVNS and anodal tDCS, cathodal tDCS is also effective in improving ADL performance after stroke." 
According to Dawson J, et al, in a randomized, blinded, pivotal device trial: "Vagus nerve stimulation paired with rehabilitation is a novel potential treatment option for people with long-term moderate-to-severe arm impairment after ischaemic stroke." 
Therefore, the requested Vagus Nerve Stimulation (VNS) for the left arm hemiparesis is medically appropriate, effective and not experimental or investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Monoplegia of Upper Limb (following cerebral infarction). 
Treatment: 64568 Open Implantation of Cranial Nerve, C1827 Generator Neurostimulator (implantable) nonchargeable, with implantable stimulation lead and external paired stimulation controller. 
The insurer denied 64568 Open Implantation of Cranial Nerve, C1827 Generator Neurostimulator (implantable) nonchargeable, with implantable stimulation lead and external paired stimulation controller. 
The denial is upheld. 

The patient is an adult male with right vertebral and basilar occlusion and brainstem strokes. He is wheelchair bound with quadriplegia. The patient was recommended vagus nerve stimulation for left arm weakness. 

The health plan should not cover the proposed treatment. 

While there is supportive evidence for this type of treatment, the mechanism is not well understood, and this has not been well accepted by the neurosurgery community and therefore is not medically appropriate for this patient with quadriplegia. "VNS for stroke/upper limb plegia does not have an adequate history of non-industry funded studies that demonstrate long term benefits. While there are large studies within the literature, these are all industry funded and there is a lack of understanding from within the neurosurgery community regarding the science and long-term outcomes associated with this procedure." For this reason, vagus nerve stimulation is still considered experimental/investigational within the neurosurgery community for upper extremity weakness and would not be considered medically appropriate for this patient. The patient should continue gold standard conservative therapy options, which include continued physical therapy amongst others. Gao Y, Zhu Y, Lu X, Wang N, Zhu S, Gong J, Wang T, Tang SW. 
Vagus nerve stimulation paired with rehabilitation for motor function, mental health and activities of daily living after stroke: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2023 Apr. 
"Determining how to achieve the clinical transformation of this technology safely and effectively is important, and more animal and clinical studies are needed to clarify its therapeutic mechanism." Cheng K, Wang Z, Bai J, Xiong J, Chen J, Ni J. Research advances in the application of vagus nerve electrical stimulation in ischemic stroke. Front Neurosci. 2022 Oct.
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 chest and abdominal pain. His medical history was remarkable for lower extremity compartment syndrome and polysubstance abuse. He also reported a history of cardiac arrest; however, the details regarding this were unclear. His electrocardiogram showed sinus rhythm without acute changes. His serum troponin level was normal. A chest X-ray and abdominal computed tomography (CT) scan showed no acute pathology. A urine toxicology screen was positive for cocaine and cannabinoids. The patient was admitted to the hospital. An echocardiogram showed a left ventricular ejection fraction of 25% with global hypokinesis; right ventricular systolic function was also decreased. Myocardial perfusion imaging showed a diffusely hypokinetic left ventricle without evidence of ischemia. Cardiac catheterization was performed and showed no obstructive disease. Guideline directed medical therapy for heart failure with reduced ejection fraction was instituted. The patient was discharged. At issue is the medical necessity for an inpatient admission.

Yes. Based on the documentation provided, an inpatient level of care was medically necessary.
This patient presented with chest pain in the setting of cocaine use. Cocaine exerts multiple effects on the cardiovascular system, including coronary vasoconstriction, platelet aggregation and increased metabolic demand, all of which may precipitate acute coronary syndrome. This patient's severe left ventricular systolic dysfunction warranted consideration of cocaine-induced myocardial injury. Particularly in light of his prior history of cardiac arrest, he was at substantial risk for malignant arrhythmias since myocardial injury and ischemia significantly potentiate the risk for cocaine-associated arrhythmias. 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: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient had a history of a serous cystadenoma requiring a surgical removal and had chronic abdominal pain. The patient also had mild hypertension. There was no abdominal rebound or guarding. An abdominal computed tomography (CT) scan did not determine the etiology of the pain. The abdominal ultrasound showed a contracted gallbladder with stones. There was no gallbladder wall thickening or pericholecystic fluid. There was mild elevation of the liver enzymes. It was felt that the patient had biliary colic. The patient's symptoms rapidly improved. 

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

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction MCG M-555 include having acute cholecystitis or acute cholangitis. The patient did not have these conditions. The patient also did not have hemodynamic instability, common bile duct obstruction, severe dehydration, or bacteremia. 

This patient had chronic abdominal pains and biliary colic. The patient did not have acute cholecystitis. Intravenous (IV) hydration and pain medications could have been given in the emergency room (ER) with observation care. The patient did not meet MCG guidelines for admission for either Undiagnosed Abdominal Pain or Gallbladder or Bile Duct Inflammation or Stone. The health care plan acted reasonably and with sound medical judgment. Inpatient admission was not medically necessary. 

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Class III skeletal malocclusion.
Treatment:  Braces, Retainer and Monthly Visits.

The insurer denied Braces, Retainer and Monthly Visits.  The denial is overturned.

This is a teenage male. The request is for orthodontic benefits, with monthly visits and retainer. The patient has a class III (3) skeletal malocclusion with moderate upper and lower jaw spacing. The prior denial was due to a score of seven on the handicapping index scale.

The requested health service is medically necessary.

The patient has a crossbite of an anterior tooth with attachment loss and gingival recession (tooth number 22). This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem and the monthly visits are needed to follow progress. The retainer is needed to prevent relapse after treatment is complete. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever with Headache and Vomiting (viral infection)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male with no significant past medical history. He presented to the ER (emergency room) with complaints of headache, sore throat, nausea and vomiting. The 
patient reported that he hit his head against the garage door while at work three weeks prior. The patient also reported headache and fever and that he took Tylenol for that. The patient's vitals in the ER (emergency room) were BP (blood pressure) 134/54, P (pulse) 106, T (temperature) 101.6, Pulse oximetry 94 percent (%). Labs showed WBC (white blood count) 8.4. Urine 
Streptococcus and legionella were negative. Testing was positive for HSV (herpes simplex virus) type 1. The patient underwent lumbar puncture to rule out meningitis/encephalitis. CSF 
(cerebrospinal fluid) cultures were with no growth. HIV (human immunodeficiency virus) test was negative. Urinalysis was negative for UTI (urinary tract infection). GAS (Group A 
Streptococcus) was negative. CRP (C-reactive protein) was 3.5, and sedimentation rate was 45. The patient's examination showed posterior oropharyngeal erythema and cervical back tenderness. EKG (electrocardiogram) showed normal sinus rhythm. The patient was admitted to inpatient hospital admission for further management. The patient was evaluated by infectious disease consult during the hospital stay, and the clinical impression was that the patient's symptoms were due to infectious mononucleosis. The patient was started on treatment with Doxycycline and Valaciclovir. ID (infectious disease) consult 
opined that bacterial infection was less likely. Testing for EBV (Epstein Barr virus) IGM (immunoglobulin M), Lyme antibody and malaria antigen was negative. The patient was given IV (intravenous) fluid, Ringer's lactate, anti-emetics and Tylenol. The patient's symptoms had improved and resolved, and he was discharged on oral doxycycline and valacyclovir.

The inpatient admission was not medically necessary.

The patient presented with symptoms related to mononucleosis like syndrome. The patient was ruled out for meningitis / encephalitis quickly after presentation and did not require treatment for such a possibility. The patient's symptoms and presentation did not show presence of hemodynamic instability, and the clinical evaluation did not show risk for immediate respiratory compromise. The patient did not have change in mental status and did not have any findings that may indicate significant systemic involvement / sepsis. Additionally, the patient was not immunocompromised. Inpatient medical admission was not medically necessary for the above duration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy. 
Treatment: Social Day Care (SDC) - Center-Based Day Care Services, per diem Increase to 3 Days per Week. 
The insurer denied Social Day Care (SDC) - Center-Based Day Care Services, per diem Increase to 3 Days per Week. 
The health plan's determination is upheld. 

This is a case review for a female with a medical history notable for intellectual disability and epilepsy. 
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with her mother in an apartment building. She was alert and oriented to person and place. She has mild intellectual disabilities with difficulty managing complex tasks. Her mother coordinates her care and manages her medications. For her instrumental activities of daily living, the patient requires total dependence on meal preparation and housework. She requires extensive assistance with finances, medications, and stairs. She requires maximal assistance for shopping. For her activities of daily living, she requires limited assistance for bathing, hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. She is independent in bed mobility and eating. She is infrequently incontinent of urine and does not use any incontinence supplies. 

The requested Social Day Care (SDC) - Center-Based Day Care Services, per diem Increase to 3 Days per Week is not medically necessary for this patient.
The patient has personal care needs secondary to intellectual disability. She receives personal care hours commensurate with the recommendation from the task tool. There were no letters provided or justification for the requested increase in social daycare services. Her care needs should be met with her current allotment of personal care hours. Therefore, the request for an increase in services is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis status-post appendectomy
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient presented with abdominal pain and vomiting. The patient was afebrile and the vital signs were stable. There were no peritoneal signs. The white blood cell count (WBC) was 13.7k (thousand). A computed tomography (CT) scan suggested an early appendicitis. A laparoscopic appendectomy was performed. There was no perforation or abscess. No complications were reported. 

Milliman Care Guidelines (MCG) guideline MG-GAS for Gastroenterology lists clinical indications for admission. Non-operative management of acute appendicitis is an indication for admission if there is a hemoperitoneum. The patient did not have a hemoperitoneum. 

MCG guideline S-175 reviews Appendectomy, without Abscess or Peritonitis, by Laparoscopy. The guideline states that the goal length of stay is Ambulatory. An inpatient stay may be required if there is a complicated appendicitis, clinically active comorbidities, wound infection, continued ileus, or postoperative bleeding. The patient did not have these complications. 

This patient underwent a laparoscopic appendectomy but did not have an abscess or perforation. She tolerated the procedure well and no complications were reported. She did not meet MCG criteria for inpatient admission under either Gastroenterology or Appendectomy without Abscess or Peritonitis, by Laparoscopy. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

The denial is upheld.

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 admission is not substantiated.