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

Diagnosis: Abnormal Heartbeat
Treatment: Implantable Cardiac Monitoring
The insurer denied: Implantable Cardiac Monitoring
The denial is overturned.

The patient is an adult female with supraventricular tachycardia (SVT) and premature ventricular contractions (PVCs) in the setting of mitral valve prolapse. She has a history of documented premature ventricular contractions and supraventricular tachycardia on Holter monitors including non-sustained ventricular tachycardia and non-sustained supraventricular tachycardia. There is a past medical history positive for atrial fibrillation. Echocardiogram and magnetic resonance imaging (MRI) were normal. Consideration for an electrophysiology (EP) study was felt to be too invasive. Implantable loop recorder (ILR) was requested. The request for implant loop recorder was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The requested Implantable Cardiac Monitoring is medically necessary.

An implantable loop recorder (ILR) or insertable cardiac monitor (ICM) is a subcutaneous, single-lead, electrocardiographic (ECG) monitoring device used for diagnosis in patients with recurrent unexplained episodes of palpitations or syncope, for long-term monitoring in patients at risk for or with documented atrial fibrillation. The appropriate indication for loop recorder is satisfied in this case. The patient has symptoms, evidence of frequent arrhythmias, and a history of atrial fibrillation. In particular, the latter would be important to start anti-coagulation even if there are rare episodes of atrial fibrillation. Per UpToDate recommendations, "Ambulatory cardiac rhythm monitoring for all patients whose initial diagnostic evaluation suggests the possibility of a disorder known to be associated with the 
development of ventricular tachycardia (VT)." The patient has demonstrated non-sustained VT (ventricular tachycardia), a condition known to be associated with sustained VT (ventricular tachycardia), syncope, and even a precursor to ventricular fibrillation. Thus, the use of a loop recorder is considered community standard and medically necessary in this clinical situation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission. The denial is upheld.

The patient presented with abdominal pain. The patient had a mild tachycardia. There was mild right lower quadrant (RLQ) tenderness but no rebound or guarding. The white blood cell (WBC) count was 12. A computed tomography (CT) scan showed cystitis and ureteritis. There was also an ovarian cyst. The urine contained large leukocytes. Antibiotics were given. The tachycardia resolved. The patient was discharged on Ciprofloxacin (Cipro).

Clinical indications for admission for a Urinary Tract Infection (UTI) (Milliman Care Guidelines [MCG] M-300) include hemodynamic instability, altered mental status, ureteral obstruction, bladder outlet obstruction, renal abscess, and acute renal failure. The patient did not have these conditions.

This patient had abdominal pain and was diagnosed with a UTI. No acute interventions were needed. The urine testing could have been done in the emergency room (ER). Afterward, the patient could have been discharged on oral Cipro. Intravenous (IV) hydration could have been given in the ER as an outpatient. No acute interventions were needed for the ovarian cyst or the gastrointestinal (GI) tract. The patient did not meet the MCG criteria for admission for a UTI. 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 acted reasonably and with sound medical judgment and in the patient's best interest.

The medical necessity for an inpatient is not substantiated.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a female with a past medical history (PMH) of hypertension (HTN), diabetes mellitus type 2 (DM2), and hyperlipidemia who was admitted with complaints of two-day history of sore throat associated with cough and body aches. Vital signs were notable for pulse 134, peripheral capillary oxygen saturation (SpO2) 98%. Physical exam notable for no apparent distress (NAD), speaking in full sentences, and well-appearing. 

The inpatient hospital stay was not medically necessary. This patient presented to the emergency department (ED) with sore throat associated with cough and body aches. The patient was found to have mild COVID-19 and treated with IVF (intravenous fluids), analgesia, and remdesivir. The patient was hemodynamically stable, did not require intubation or non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, or hypoxia on admission. In addition, the patient did not have a high-risk 4C COVID-19 mortality score. The patient was diagnosed with COVID-19 without sepsis or hypoxia and treated with IVF, analgesia, and remdesivir, and these interventions could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Nausea and Vomiting
Treatment: Inpatient Hospital
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who presented to the emergency department (ED) with 3 days of abdominal pain, vomiting, nausea, and diarrhea. His past medical history was significant for a prior subtotal abdominal colectomy with ileorectal anastomosis.  He has had multiple episodes of small bowel obstruction since the time of the subtotal colectomy. Lab abnormalities were attributed to hemoconcentration with acute kidney injury. The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed a dilated small bowel without identification of a point of obstruction. The physical examination on  documented a nontender abdomen.
The patient was admitted to the hospital and treated with intravenous (IV) fluid, antiemetics, and pain medication.  He was started on a liquid diet. He was considered to be stable for discharge from the hospital. At issue is the medical necessity of an inpatient stay.
Inpatient stay was not medically necessary for this patient.
The submitted records support that this patient presented with 3 days of abdominal complaints. He was also status post-surgery that included prior subtotal abdominal colectomy with ileorectal anastomosis. The computed tomography (CT) scan showed dilated small bowel but was not indicative for small bowel obstruction and while he was dehydrated with elevated hemoglobin and elevated creatinine at the time of presentation, his condition promptly normalized within one day of presentation. He had normal vital signs and a normal abdominal exam per the admitting history and physical (H&P). He was treated with nothing by mouth (NPO) status, IV fluid, and follow up x-ray. He was monitored with daily examination and surgical consultation. His condition did respond promptly and favorably and he did not need nasogastric decompression or surgical treatment.
The submitted records include Milliman Care Guidelines (MCG) Abdominal Pain, Undiagnosed 27th edition that state that admission is indicated for 1 or more of the following: hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs, identification of etiology or finding that requires inpatient care, evaluation requires patient to not eat or drink for an extended period (more than 24 hours), inability to maintain oral hydration, suspected toxic megacolon, bacteremia.
In this case, none of these conditions existed to support the medical necessity of inpatient admission. He had normal vital signs and was able to drink within one day of presentation.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a woman who presented after a slip and fall incident, in which she fell down 3 steps. There was a brief loss of consciousness at the scene of injury. In the ED (emergency department) she reported dizziness, headache and diffuse musculoskeletal pain. The Glasgow Coma Score was 15 at the time of presentation. She was evaluated with computed tomography (CT) scans and x-rays that were negative for acute intracranial, intrathoracic or intra-abdominal injury or bone fracture. She was admitted to the hospital for serial neurological exams.

The inpatient hospital admission was not medically necessary. This patient presented to the hospital following a head injury (concussion) that resulted from a slip and fall event. The submitted records support that she was clinically and hemodynamically stable at the time of arrival to the Hospital. Her diagnostic evaluation did not identify acute injury that required surgical intervention, and she was able to tolerate oral intake and medications. Following physical therapy evaluation, she was able to be discharged home with post-discharge follow up instructions.
Per the Milliman Care Guidelines (MCG): Admission is indicated for head injury and one or more of the following: Hemodynamic instability, altered mental status that is severe or persistent, Post-resuscitation or presenting Glasgow coma score of < (less than) 13, worsening neurologic function, new signs or symptoms, new focal signs on neurologic examination, evidence of increased intracranial pressure, new intracranial pathology on imaging, cerebrospinal fluid (CSF) leak, recurrent seizures, significant respiratory abnormalities secondary to the brain injury, increased intracranial pressure or cerebral edema monitoring. In this case none of these neurological criteria were present to warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion
Treatment: braces
The insurer denied Braces.
The health plan's determination is upheld.

The patient in question is a male with a Class I occlusion. He has 5-millimeter (mm) overbite and 4mm overjet. He has moderate maxillary and mandibular crowing. He is in the mixed dentition stage of dental development with seven remaining primary teeth. The patient is treatment planned for braces to correct his malocclusion.

Braces are not medically necessary for this patient.
He has crowding but no teeth are impacted. His overbite is deep but there is no indication of wear on the mandibular incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the upper incisors in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present.
There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the mandibular teeth or palatal soft tissue damage from their current position. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: abdominal pain/vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a female with a past medical history (PMH) of tobacco use, Hashimoto's, GAD (general anxiety disorder), and marijuana use who was admitted with complaints of abdominal pain associated with nausea and vomiting. Vital signs were unremarkable. Physical exam was notable for mild distress, abdomen soft with mild tenderness to palpation (TTP). Lab work was unremarkable. A computed tomography (CT) A/P (abdomen/pelvis) showed no acute intra-abdominal or pelvic inflammatory process. 

The inpatient hospital stay was not medically necessary. This patient presented to the emergency department (ED) with complaints of abdominal pain associated with nausea and vomiting. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with cannabinoid hyperemesis without acute imaging, was treated and responded to IVF (intravenous fluids), anti-emetics, BZDs (benzodiazepines), and pain control, and clinically improved within 24 hours of admission. These interventions could have been safely and appropriately been provided a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: 64628 Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance First 2 Vertebral Bodies, Lumbar or Sacral
The insurer denied 64628 Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance First 2 Vertebral Bodies, Lumbar or Sacral.
The denial is upheld.

The patient is an adult female with low back pain which began 8 years ago. Past treatments include physical therapy, acupuncture, epidural steroid injections, radiofrequency ablations, Tizanidine, Cyclobenzaprine, Naprosyn, Celebrex, Gabapentin, Lyrica, Meloxicam, Diclofenac, and Cymbalta. The patient's pain is a 10/10. MRI (magnetic resonance imaging) of the lumbar spine shows multilevel disc disease and facet arthropathy most advanced at (Lumbar) L4-5 with mild/moderate left foraminal narrowing and mild right foraminal narrowing. The request for Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

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 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 requested health service. Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e. NSAIDs [non-steroid anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e. physical therapy, home exercise program, chiropractor treatments), and interventions (i.e. epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: 64628 Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance First 2 Vertebral Bodies, Lumbar or Sacral
The insurer denied 64628 Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance First 2 Vertebral Bodies, Lumbar or Sacral.
The denial is overturned.

The patient is an adult female. Per the appeals letter, the patient has chronic back pain due to degenerative disc disease that resulted in vertebrogenic pain identified by degenerative endplate changes on MRI (magnetic resonance imaging). The patient had pain and failed treatment for greater than six months. Prior treatments include lumbar epidural steroid injection, medication, physical therapy, radiofrequency ablation as well as transforaminal epidural steroid injections. Per a noted dated four months ago, the patient presents with low back pain status post radiofrequency ablation bilateral lumbar with minimal relief. Pain is 10/10. MRI (magnetic resonance imaging) had demonstrated Modic type changes present at (Lumbar) L5-S1 (Sacral) as well as L4-L5.

The health plan should cover the requested health service.

Based on the documentation provided and per current literature, the requested procedure is recommended at this time. The patient has a history of continued back pain despite prior conservative treatments, including medication, activity modification as well as physical therapy. Additionally, the patient has tried multiple injection therapies including epidural steroid injections, radiofrequency ablations as well as transforaminal epidural steroid injections with continued symptoms. MRI (magnetic resonance imaging) had demonstrated Modic type changes. The requested procedure is FDA (United States Food and Drug Administration) approved and recommended for patients with such findings on imaging.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: 64628 Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance First 2 Vertebral Bodies, Lumbar or Sacral
The insurer denied 64628 Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance First 2 Vertebral Bodies, Lumbar or Sacral.
The denial is overturned.

The patient is an adult female with low back pain. She had an MRI (magnetic resonance imaging) which demonstrated mixed Modic type I and II changes in the (lumbar) L4 and L5 vertebral bodies. This was felt to be the primary cause of the patient's chronic low back pain. She has tried lumbar epidural steroid injections, medication management (Cyclobenzaprine, Diclofenac Gel, Lidocaine patches, and Tizanidine), physical therapy, and radiofrequency ablations, all without significant relief. She tried these strategies for 6 months. Her ability to perform ADLs (activities of daily living) such as bending/lifting, sexual activity, sleeping, and work have all been affected. The treating provider requests approval for basivertebral nerve ablation to treat the patient's chronic vertebrogenic pain in light of this. Initial review by the health plan denied coverage for the request for basivertebral nerve ablation due to experimental/investigational status, and the first appeal upheld this decision. Second appeal also upheld this decision. The denial is being appealed.

The health plan should cover the requested health service.

The patient has tried and failed standard medical management for six months. These include lumbar epidural steroid injections, medication management (Cyclobenzaprine, Diclofenac Gel, Lidocaine patches, and Tizanidine), physical therapy, and radiofrequency ablations. All have failed to provide relief of her chronic low back pain. She has MRI (magnetic resonance imaging) evidence of Modic changes indicating vertebrogenic changes, and this is a known etiology of chronic low back pain. Basivertebral nerve ablation is an appropriate procedure to treat this etiology of pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Stay

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

The patient is a male with a medical history of hepatocellular carcinoma, Budd-Chiari syndrome, cirrhosis complicated by esophageal varices and spontaneous bacterial peritonitis, schistosomiasis, and diabetes mellitus. He presented to the emergency department with three days of abdominal pain, chest pain, back pain, neck pain, nausea, vomiting, and fever. He had recently been admitted with abdominal pain and constipation, which resolved with the treatment of constipation. Vital signs were unremarkable. Physical examination was notable for acute distress, ill appearance, conjunctival injection, right upper quadrant tenderness with guarding, and back tenderness.

The inpatient hospital admission is not medically necessary in this case. The patient presented with constipation; however, after brief conservative observation and management with osmotic laxatives, he had bowel movements and symptom resolution. He was found not to have ischemic colitis, peritonitis, abscess, perforation, fistula, or other complications. Additionally, he did not have any acute complications of his severe liver disease, such as variceal bleeding, acute liver failure, spontaneous bacterial peritonitis, or hepatic encephalopathy. Given the lack of complications, the monitoring and treatment could have been performed without the inpatient level of care. For these reasons, the inpatient level of care is not supported based on the provided information.