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

Diagnosis: Small bowel intussusception
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a patient who presented to the emergency department (ED) on with acute onset abdominal pain, nausea, and vomiting of 2-days duration. His past medical history was significant for marijuana abuse. His heart rate at the time of presentation was 80 beats/minute. The abdomen was tender on the right side. The white blood cell count (WBC) was normal at 8.9 thousand (K). The potassium and renal function were normal. The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed a small bowel intussusception without findings of a small bowel obstruction.
The patient was admitted to the hospital surgery service and was treated with intravenous (IV) fluid, antiemetics, and pain medication. The admitting diagnosis was small bowel intussusception. He was initially kept nothing by mouth (NPO). The patient left the hospital against medical advice (AMA).

The inpatient stay was not medically necessary for this patient.
The medical records support that this patient presented to the ED with acute abdominal pain. His clinical condition including examination, lab results, and imaging did not identify an acute bowel obstruction or other medical condition that required urgent surgical intervention. The precise nature of the pathology was uncertain. The vital signs and lab data were normal. He was admitted to the hospital with plans to monitor him clinically and with additional imaging. There was no documentation of hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs, need for identification of etiology or finding that requires inpatient care (aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction) evaluation requires patient to not eat or drink for more than 24 hours, inability to maintain oral hydration that persists after observation care, suspected toxic megacolon, bacteremia, procedure needed that cannot be performed on ambulatory basis.
In this case the patient's condition could have been appropriately managed with a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar back pain. 
Treatment: Intraosseous basivertebral nerve ablation (procedure code 64628). 

The insurer denied coverage for intraosseous basivertebral nerve ablation (procedure code 64628). 

The denial is upheld. 

This patient has chronic low back pain. He has had a microdiscectomy as well as injection therapy. He has tried Physical Therapy. His medication trials have included Advil, Aleve, cyclobenzaprine, Gabapentin, Ibuprofen,Tramadol and Tylenol. A magnetic resonance imaging study (MRI) shows Modic type 1 changes at lumbar (L) 4 and L5. The request is for radiofrequency (RF) ablation of the basivertebral nerves (BVN). 

Long-term comparative outcomes are not known. The publications to date have been company sponsored and had methodology flaws. There is no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. 

A clinical practice guideline (4) while favorable pointed out the limitations of the current literature: 
- Industry funding is a potential source of study bias for the available data reviewed. 
- Limited number of studies. 
- Short-term follow up for the majority of studied patients. 
- Unknown effect on the primary degenerative process. 

Peer reviewed literature does not support a result of improvement in health outcomes with the requested procedure. The requested procedure does have final regulatory approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not a good candidate for the requested procedure.  It is not the best available treatment for this patient at this time. 

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments. 
In summary, the denial of  intraosseous basivertebral nerve ablation (procedure code 64628) and coverage for the requested procedure should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Kidney Disease (CKD)
Treatment: Tarpeyo
The insurer denied: Tarpeyo
The denial is: Upheld

The patient is a male with a history of testicular cancer, hypertension (HTN), vitamin D deficiency, Barrett's esophagus and chronic kidney disease (CKD) stage 4. He underwent a recent native kidney biopsy which showed advanced nephropathy most likely due to immunoglobulin A (IgA) nephropathy. His most recent estimated glomerular filtration rate (eGFR) was under 20 with a urine protein/creatinine ratio of 4.2. The patient is currently on chlorthalidone 25 milligrams (mg) daily, Lipitor 20mg daily, losartan 25mg daily and Norvasc 10mg daily. The provider prescribed Tarpeyo to further manage his IgA nephropathy. The health care plan has denied this request as it did not meet their Pharmacy Management Drug Policy criteria. The subject under review is the medical necessity for Tarpeyo.

The health plan's determination is upheld.

Tarpeyo is a corticosteroid Food and Drug Administration (FDA) approved to reduce proteinuria in adults with primary immunoglobulin A nephropathy (IgAN) at risk of rapid disease progression, generally a urine protein-to-creatinine ratio (UPCR) greater than or equal to (>=) 1.5. It has not been established whether Tarpeyo slows kidney function decline in patients with IgAN. The randomized control studies looking into the benefit of Tarpeyo have limited therapy to patients with eGFR greater than 35 and on maximal doses of angiotensin II receptor antagonists or angiotensin converting enzyme inhibitors. The patient dose not fulfill these criteria based on the documentation provided (eGFR less than 20 and not on maximal angiotensin II receptor blocker therapy), therefore the use of Tarpeyo in this case is not medically necessary. It is not yet established that Tarpeyo would be of benefit in a patient such as the one in this case.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Pelvic inflammatory disease
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission. 
The denial is modified.
	
The patient is a female who presented to the hospital complaining of abdominal pain, vaginal discharge, and fever. Temperature was 102.2. Abdominal exams show abdominal tenderness in the right lower quadrant suprapubic area and left lower quadrant. Pelvic exam shows significant cervical motion tenderness. She was admitted with a diagnosis of pelvic inflammatory disease (PID) and maintained on cefoxitin and doxycycline. She responded well to treatment and was afebrile 24 hours after admission.

However, the patient was noticed while admitted having hepatosplenomegaly and anemia. She was kept in-house for completing the work-up of hepatosplenomegaly. She was to start iron supplements, finish antibiotics and follow up with primary care physician and hepatosplenomegaly as an outpatient. 

Most females with PID can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include:

1) Severe clinical illness (eg ["for example"], fever greater than or equal to 38.5 [degrees] Celsius [101Fahrenheit], nausea and vomiting) 2) Complicated PID with pelvic abscess (including tubo-ovarian abscess) 3) Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess 4) Inability to take oral medications 5) Pregnancy 6) Lack of response or tolerance to oral medications 7) Concern for nonadherence to therapy.

This patient has nausea and vomiting with concern about her ability to take oral medications. In addition, there was concern for nonadherence to therapy as she has been seen three times for the same condition.

Based on the above, and due to the elevated temperature and severity of the pain, admission was medically necessary. However, by the third day, the patient was afebrile and stable and could have been discharged on oral antibiotics. Note that the workup for anemia and hepatosplenomegaly could be performed as an outpatient.

The hospital admission for the initial two days is considered medically necessary for this patient. Continuous admission for the next two days was not. 

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicide attempt by overdose

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This adult male reportedly was admitted to this inpatient psychiatric hospital due to a suicide attempt by overdose with intent to die, depressed mood, hopelessness and helplessness, isolation, withdrawal, anxious mood, impaired judgment and insight, concentration problems, and low motivation. He reportedly had falls and dizziness and was lightheaded, so he was transferred to telemetry for medical monitoring and had 1:1 observation for suicide. He reportedly was medically cleared and transferred back to the psychiatric unit. He reportedly continued with depressive symptoms including depressed mood, hopelessness and helplessness, low motivation, and isolation. He had medication changes including trying and discontinuing Effexor, discontinuing Aripiprazole, and he took Fluoxetine, had Gabapentin and Clonazepam started, and took Atarax. He gradually improved enough for discharge. 
  
The medical records provided enough specific evidence to support that the patient required 24-hour hospital treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide and also that hopelessness increases the risk of suicide. This patient was considered at risk for further suicide if not in a 24-hour hospital setting, as he reportedly had a suicide attempt by overdose, and it was his second one within a 2-month period which put him at high risk for suicide and another attempt while still reporting depression. Notes reported that he still had depressed mood, was isolative, distractible, had minimal interaction, had passive suicidal ideation, low motivation, welcomed death, and residential treatment for discharge when stable was being considered. 

Notes reported that he was less depressed and anxious but worried about leaving so he started to show some improvement. He reportedly was improved enough and was discharged. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with risk factors for suicide may need to be observed for longer periods in an inpatient hospital to better ensure their safety, as some may not tell the truth about their continued wish to suicide while in the hospital so they can be discharged and complete suicide. This patient continued to report depressed mood, hopelessness and helplessness and was not improved clinically enough for discharge when it was reported that he had bright affect and was calmer, was hopeful with no helplessness, was future oriented, motivated, had no suicidal thoughts, and was considered psychiatrically stable.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for the continued inpatient mental health treatment is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: nonischemic cardiomyopathy
Treatment: LifeVest
The insurer denied: LifeVest
The denial is: Upheld

The patient is a female with a history of hypertension, hyperlipidemia, diabetes, obstructive sleep apnea, obesity and nonischemic cardiomyopathy. At the time of diagnosis, her left ventricular ejection fraction (LVEF) was 30%. She was evaluated for exertional dyspnea; at that time, she had not had cardiology follow-up or treatment for her cardiomyopathy for approximately two years. An echocardiogram showed an LVEF of 30-35%. Metoprolol, losartan and spironolactone were prescribed. A LifeVest wearable cardioverter defibrillator (WCD) was prescribed for primary prevention of sudden cardiac death. Implantation of an implantable cardioverter defibrillator (ICD) was recommended. Cardiac magnetic resonance imaging (MRI) showed an LVEF of 32%; there was no evidence of fibrosis, inflammation or infiltrative cardiomyopathy. The patient's losartan was discontinued and Entresto was prescribed. The office note from that date indicated that she was wearing a LifeVest. By echocardiogram, the patient's LVEF was 30-35%. A note indicated that arrangements would be made for ICD implantation.
The subject under review is the medical necessity for the requested LifeVest.

The health plan's determination is upheld.

Based on the information provided the WCD was not medically necessary.
This patient was evaluated for exertional dyspnea. She was found to have a left ventricular ejection fraction (LVEF) of 30-35%. While she had previously been diagnosed with a nonischemic cardiomyopathy, she was not on guideline-directed medical therapy when seen.

The efficacy of the WCD in detecting and terminating serious ventricular arrhythmias compares favorably to that of the implanted device. In the published clinical studies, the vast majority of episodes of rapid ventricular tachyarrhythmias were successfully treated by the device. Unlike the ICD, however, one of the largest barriers to the overall effectiveness of the WCD is lack of compliance. Even highly compliant patients cannot wear the WCD continuously as it must be removed for bathing and changed for washing. It is not intended as a replacement for an ICD but, rather, as a "bridge" to potential ICD implantation for patients who are at risk for malignant arrhythmias but not immediately eligible for an ICD. Unlike with the ICD, there are no data that long-term use of the WCD improves cardiovascular outcomes. The medical records provided suggest that this patient would have been eligible for ICD implantation; they do not indicate that there was a contraindication to device implantation at that time. Thus, use of the LifeVest for the time period at issue, was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


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

The patient is a male infant who presented with projectile vomiting. He had a history of reflux since birth, and was switched from Enfamil Gentlease formula to Nutramigen. However, his symptoms of reflux continued and worsened over time. On the day of presentation, he developed forceful, projectile vomiting, and had 3 episodes approximately 30 minutes after a feed.
In the emergency department, he appeared hungry and was felt to be mildly dehydrated. An abdominal X-ray and ultrasound were obtained. The ultrasound revealed a thickened pylorus with elongation, consistent with hypertrophic pyloric stenosis. He was given a bolus of normal saline, started on maintenance intravenous fluids, and was admitted to the hospital for further care.

Inpatient Hospital Stay was medically necessary for this patient.
The effects of pyloric stenosis, including dehydration and electrolyte imbalance, can be serious. Infants presenting with normal electrolyte values and mild dehydration should receive maintenance intravenous fluids. Infants with pyloric stenosis are also at risk for apnea postoperatively because of their young age and effects of anesthesia.
This patient presented with a long history of reflux and recent projectile vomiting with an inability to keep fluids down. He required intravenous fluid hydration and prompt surgical treatment for pyloric stenosis, including post-operative hydration with a re-feeding protocol and close monitoring. For this level of required care, an inpatient admission is appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontitis

Treatment: a bone replacement graft D7953, for first molar on the upper left - tooth #14

The insurer denied a bone replacement graft D7953, for first molar on the upper left - tooth # (number) 14

The insurer's denial was upheld.

According to the documentation submitted, this is a patient with no significant documented history. The dentist stated that the patient presented to his office with fluctuant swelling on the buccal aspect of #13 & #14 and pocket depths ranging from 4-6 (mm) millimeters, bleeding upon probing, and clinical loss of attachment. Osseous surgery was performed. 

Based on the submitted documentation which includes copies of full mouth series radiographs, periapical radiographs, periodontal chartings, narrative letters, and insurer correspondence, it appears that this patient presented for evaluation and management of infection site #13/14. Based on the clinical and radiographic findings the dentist performed osseous surgery and recommended the aforementioned service of bone graft. The insurer has denied this service stating that the documentation provided does not support it as it does not meet their criteria which included at least 5 mm pocket depths. Therefore, they are deemed not medically/dentally necessary. The patient is appealing.

Based on the clinical and radiographic information provided for review the alveolar bone height is acceptable on submitted radiographs and presumably this same level of bone was noted at time of surgery. Periodontal pocket depths in the area of concern do not measure greater than 3-4 mm over the course of several years. There does not appear to be a progressive loss of alveolar bone. Therefore, although this service could be done it is optional for this patient and would be deemed performed for the convenience of the patient. Although there is literature to support that bone graft would be helpful in maintaining bone height (see references below), again this would be considered an optional procedure and not one that is considered medically necessary in this circumstance.

The grafting procedure performed on this patient was not medically necessary. There is no absolute requirement that the bone graft be performed at the time of surgery and the documentation provided for review does not support, justify or substantiate the requested service.

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 a bone replacement graft D7953, for first molar on the upper left - tooth #14 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Stomach Pain
Treatment: Hospital admission
The insurer denied hospital admission
The denial is: Upheld

The patient is a previously healthy female who presented to the emergency department (ED) with abdominal pain of 2-hours duration. At the time of presentation, the patient was without fever, her heart rate was 65 beats per minute (bpm), and her blood pressure was 122/81 millimeters of mercury (mmHg). She was tender in the epigastrium. The white blood cell (WBC) count was elevated at 14.6. The complete metabolic panel identified normal liver enzymes and bilirubin. An ultrasound and computed tomography (CT) scan showed gallstones, thickening of the gallbladder wall, and a normal caliber extrahepatic bile duct.
She was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. Surgery consultation was requested. She was treated with a laparoscopic cholecystectomy. The operative dictation recorded completion of the procedure without complication with findings of an inflamed gallbladder. The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, antibiotics, and antiemetics. The WBC count had normalized to 5.7. The diet was advanced, and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting.
The material submitted for review includes Milliman Care Guidelines (MCG) 26th edition Cholecystectomy by Laparoscopy.
MCG state that the goal level of care is observation, but that extended stay or inpatient care may be needed when there is:
1) Failure to achieve discharge status
2) Conversion to open procedure
3) Severe systemic infection that delays surgery
4) Severe infection postoperatively
5) Care for active comorbidities
6) Complications of procedure
7) Gallstone ileus

At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of hospital admission was not medically necessary for this patient. This patient was a female who presented to the ED on with abdominal pain of 2-hours duration. She was evaluated with labs, CT scan, and abdominal ultrasound. Based on the clinical history, labs, and imaging, she was diagnosed with cholecystitis. Surgery was performed without complication, and the patient was deemed suitable for discharge from the hospital on the first post-surgical day. Acute inpatient care was not medically necessary for this patient and this level of care was not supported by MCG 26th edition, Cholecystectomy by Laparoscopy.
The care provided during this period of time could have appropriately and reasonably been rendered with an alternate level of care.