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

Diagnosis: obstructive sleep apnea

Treatment: Reconstruction midface, endoscopically assisted surgical expansion (EASE)

The insurer denied coverage for Reconstruction midface, endoscopically assisted surgical expansion (EASE)

The denial is overturned

The patient is an adult female with midface deformity and nasal obstruction. The patient is in college and has severe sleep apnea. Continuous positive airway pressure (CPAP) was trialed without benefit. Symptoms include daytime fatigue. The examination revealed nasal aperture stenosis and maxillary malformation. The patient has previously had jaw surgery and still has symptoms. The request is for procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. Examples include:

The procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system does have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is a good candidate for procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system.     

The procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system is the best available treatment for this patient at this time.     

The adverse risks are not increased over standard treatments.     

The procedure is more likely to be beneficial than any other procedures for this patient. She has had jaw surgery, trialed CPAP, and has notable stenosis of the nasal aperture with maxillary malformation. This surgical procedure is the next best step for improvement in quality of life.                                                    

In summary, the denial of procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system and coverage for the requested service/treatment should be overturned. 

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Planned kidney procedure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult female underwent percutaneous coiling of a 3 centimeter (cm) bilobed left renal artery aneurysm. The procedure was uneventful. Progress notes show that the patient had left flank and abdominal pain, controlled with pain medications. She was admitted overnight. By the following morning, the pain was improved and well controlled. The patient requested discharge, and her medical team agreed.

The requested health service was not medically necessary.

The patient had a routine course after percutaneous coiling of a 3 centimeter bilobed left renal artery aneurysm. She did not have any serious complications such as bleeding or renal failure. She had moderate pain in the left flank and abdomen. This is not unusual after renal artery coiling. Her pain was adequately controlled with pain medications and substantially improved by the following morning, to the degree that she requested to be discharged. There was nothing about her pain that mandated acute inpatient admission. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic back pain

Treatment: procedure code 64628, intraosseous basivertebral nerve ablation

The insurer denied coverage for procedure code 64628, intraosseous basivertebral nerve ablation

The denial is upheld 


This adult patient has chronic low back pain. The patient has tried and failed conservative therapy.  The patient has Modic Type I changes at L (lumbar) 3 - L 4 and the request is for radiofrequency ablation (RFA) of the basivertebral nerves (BVN) at those levels.

In 2018, Fischgrund and colleagues published a double-blind, sham-controlled randomized controlled trials (RCT) evaluating the Intracept system and radiofrequency (RF) ablation of the Basivertebral nerve for the treatment of chronic low back pain. The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months... At 3 months, in the ITT analysis, there was no statistically significant difference between groups in the primary outcome, mean ODI. 

A second randomized controlled trials (RCT) evaluating the Intracept system, known as the INTRACEPT trial, was published by Khalil and colleagues in 2019. The trial was open label and compared intraosseous radiofrequency (RF) treatment to standard care in individuals with at least 6 months of chronic low back pain who had not responded to at least 6 months of conservative care... Limitations of this study include the lack of a sham control and limited duration of follow-up.

Conger et. al., pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline, 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

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 procedure code 64628, intraosseous basivertebral nerve ablation services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	Cholelithiasis	

Treatment:     Inpatient admission

The insurer denied inpatient care

The denial is upheld

The patient is an adult male, who presented to the emergency department (ED), from home, with complaints of worsening right upper quadrant abdominal pain, of 2 days duration. The patient denied fever, nausea, vomiting, chest pain, shortness of breath, headache, or dizziness. The pain level was reported as 8/10; Temperature was 97 degrees Fahrenheit; Blood Pressure 145/75 mmHg (millimetres of mercury); oxygen saturation 100% on room air. The patient endorsed a medical history of cholelithiasis.  On examination, the patient was noted in mild distress; remarkable for tenderness upon palpation. 

Laboratory studies showed white blood cell (WBC) count 10.8, Neutrophil 83.4%, ANC 9.0, Glucose 134, Creatinine 1.45, Aspartate Transaminase (AST) 97, Alanine Transaminase (ALT) 78, and Total Bilirubin 2.2. Abdominal Ultrasound showed Cholelithiasis, and echogenic liver which may be secondary to pattern steatosis. The patient received Sodium Chloride 0.9% 1 Liter intravenous (IV) bolus STAT (immediately), Morphine 2mg (milligrams) IV STAT, and Ondansetron 4mg (milligrams) IV STAT. Surgery was consulted and in setting of acute symptomatic cholelithiasis, the patient was deemed unstable for discharge. 

The patient was admitted for Symptomatic Cholelithiasis. The treatment plan included a surgical consultation, repeat laboratory work, serial abdominal exams, continuous intravenous (IV) fluids, IV antibiotics, IV pain medication, and IV antiemetics. On the morning reassessment, the patient no longer experienced pain, was without leukocytosis, and was tolerating a diet.  Due to this improvement in clinical status, the patient was discharged with prescribed Augmentin and discharge instructions for outpatient cholecystectomy surgery.      

Per the literature references, in absence of ultrasound findings, those that do not meet the diagnostic criteria for cholecystitis are often discharged with a diagnosis of symptomatic cholelithiasis with recommendations for outpatient surgical follow up for an elective cholecystectomy. 

According to the MCG (Milliman Care Guidelines) 27th edition, Gallbladder or Bile Duct Inflammation or Stone criteria for an inpatient admission. The patient's condition did not meet criteria for inpatient admission. Although there was a noted presence of cholelithiasis on the ultrasound imaging, there was no noted obstruction. The patient did not have unstable vital signs, pain, vomiting or dehydration which persisted despite emergency room care. The clinical documentation did not indicate recommendations for a stat surgical intervention to support the inpatient admission.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The adult patient presented with abdominal pain, nausea, and constipation. He had a history of polysubstance abuse. He was afebrile and vital signs were stable. There was no abdominal rebound or guarding. The creatinine had increased from 1.26 to 1.47. The creatine phosphokinase (CPK) was elevated. An abdominal computed axial tomography (CAT) scan was negative for acute disease but found adrenal nodules. Intravenous (IV) hydration and potassium replacement were given. The CPK improved. Proton-pump inhibitors (PPI) treatment and Zofran were given for gastritis and the symptoms improved. The creatinine came down to 1.14. 

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

Clinical indications for admission for Acute Renal failure (MCG M-326) include having stage 3 acute renal failure such as a rise in creatinine to 3 times the baseline or acute kidney injury with additional indications. These additional indications include hemodynamic instability, severe cardiac arrhythmias, altered mental status, severe hypertension, severe respiratory findings, and severe electrolyte or metabolic abnormalities. The patient did not have these conditions. 

This patient had abdominal pain and was treated for gastritis. PPI therapy and Zofran could have been given in the emergency room (ER) as an outpatient. He was also diagnosed with rhabdomyolysis. However, IV hydration could have been given with observation care. The creatinine and CPK improved with the IV hydration. The patient did not meet MCG criteria for admission for either undiagnosed abdominal pain or acute renal failure. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift).
The health plan's determination is overturned.

The patient is a female with a history of Alzheimer's disease, hypertension, dyslipidemia, congestive heart failure, venous insufficiency, bilateral knee osteoarthritis, sciatica, anemia, weakness, recurrent urinary tract infection (UTI), and urinary and fecal incontinence. She lives alone in a 1-bedroom apartment. She has equipment at home consisting of incontinence supplies, wheelchair, walker, shower stool, and hospital bed. 

Personal Care Aide (PCA) services for 168 hours per week (split shift) is medically necessary.
The Plan-approved services are insufficient to meet the patient's needs. There is documentation in the Uniform Assessment System (UAS) of the patient being totally dependent for the task of toilet use and requiring maximal assistance with task of bed mobility. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. The patient lives alone and does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL) of diaper changes and bed mobility.
24-hour live-in care would not be appropriate for this patient. Per NY Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient would be unable to receive five hours of uninterrupted sleep. The patient's PCP (primary care provider) documented the need for the patient to be changed and repositioned every 2 hours. The patient has a documented sacral pressure ulcer. As noted in "Pressure Injuries: Prevention, Evaluation, and Management", patients with pressure injuries need to have the skin kept clean (particularly following incontinence events) and need to be encouraged to position often, with assistance if necessary. Increased moisture from urine, stool, and sweat can cause skin maceration and escalate the risk of pressure injuries and prevent healing of existing pressure injuries. Therefore, split-shift care is required to meet the patient's frequent care needs throughout the night.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: nondisplaced tibial fracture

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult male who was riding an electric scooter and was hit by moving car. He was unable to ambulate and had no other complaints.  He had a previous history of chronic kidney disease and hypothyroidism. He was evaluated in emergency department (ED) and diagnosed with a tibial plateau fracture. His pain level in the ED was 4/10. He underwent several other diagnostic studies which did not reveal other fractures. Nursing records describe him resting comfortably. 

He was evaluated by Orthopedics and noted to have a subtle nondisplaced fracture to the medial tibial plateau. He was provided with a knee immobilizer and advised to be non-weight bearing. Additional appointments were provided for outpatient follow-up. Reportedly he could not go home as he lived on the second floor and could not do stairs. He was then admitted to medicine for rehab evaluation.  

The medical records show the patient sustained an isolated minimally displaced tibial plateau fracture. There were no other reported injuries. The orthopedic service provided a knee immobilizer. No surgery was recommended with follow-up as outpatient. The records show pain levels to be satisfactory with no need of parenteral analgesia. There were no limitations to use of crutches and to be non-weight bearing. There were no other medical conditions to require treatment. There were no additional imaging studies or tests which were necessary. The reported reason for admission was "he could not go up two flights of stairs at home". 

No Milliman Care Guidelines (MCG) criteria were fulfilled. The level of service could have been at lower level as there were no extenuating circumstances to substantiate the admission and level of 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 Admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who had recently returned from his home country, Senegal, after a 5 month stay. He presented to the emergency department (ED) with fevers, HAs (headaches), myalgias and some nausea. 

The Inpatient hospital admission was not medically necessary.
This patient presented to ED with nonspecific symptoms and was discharged with diagnosis of viral syndrome. He returned and was found to have malaria. Lab abnormalities included hyponatremia, elevated Tbili (total bilirubin) 2.7 with direct 1.1, normal white blood cell count (WBC) and thrombocytopenia. He was noted as alert and oriented x 3. His breathing was unlabored with normal respiratory rate and 100% on room air (RA). His abdomen exam benign. His renal function was normal. His Hgb (hemoglobin) was 12.8. His transaminases were normal. His lactate was < (less than) 1.0. He was started on Coartem and supportive care, and electrolytes were repleted as indicated. His peripheral smear was negative for parasites.
This patient did not have manifestations of severe malaria. Hospitalization for adults with uncomplicated malaria may be appropriate for patients who are immune compromised, patients with hyperparasitemia but no signs of severe infection, as they are at increased risk for progression to severe malaria and/or treatment failure.
It would have been reasonable to treat this patient at a lower level of care as he did not have manifestations of severe malaria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This is the case of a patient that presented to the hospital with complaints of nausea, vomiting and abdominal pain. Past medical history was significant for diabetes mellitus and hypertension. The patient reported drinking large amounts of tequila daily prior to admission. On arrival to the hospital vital signs revealed hypertension and tachycardia (blood pressure [BP] 222/98, Pulse 100). Physical examination revealed an ill appearing individual with abdominal tenderness without rebound or guarding.  12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm without ischemic ST or T wave abnormalities. Serum blood testing revealed an elevated high sensitivity troponin at 550. COVID-19 testing was positive. The patient was admitted to the hospital for testing and treatment.  Computed tomography (CT) angiography demonstrated no evidence of aortic dissection.  Echocardiogram was ordered and the patient was treated with an antihypertensive. The patient also received treatment for alcohol withdrawal. The patient signed out against medical advice one day after presentation.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with abdominal pain, poorly controlled hypertension and an elevated serum troponin level.  The patient's pretest probability of coronary artery disease is intermediate (1) Utilizing the HEART (History, ECG, Age, Risk Factors, Troponin) score the patient was considered intermediate risk (2). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. The patient presented with poorly controlled hypertension and alcohol withdrawal that likely contributed to a type 2 myocardial infarction (4).

 In conclusion, given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate.

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 an inpatient admission is substantiated.
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 has sickle cell disease and presented with abdominal pain. There was a prior history of cholelithiasis and choledocholithiasis requiring an endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was a mild elevation of the aspartate aminotransferase (AST) and the bilirubin was elevated. The patient was diagnosed with symptomatic cholelithiasis and a laparoscopic cholecystectomy was performed. The patient was transfused with one unit of packed red blood cells post-operatively.  The patient tolerated the procedure and no further complications were reported. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (Milliman Care Guidelines [MCG] M-555) include having acute cholecystitis with abdominal pain, systemic signs of inflammation, and when a cholecystectomy is not anticipated. In this case, there was a plan to do a cholecystectomy. Performing a laparoscopic cholecystectomy can be done as an ambulatory procedure when there are no complications. In addition, the patient did not have acute cholangitis, hemodynamic instability, common bile duct obstruction, severe vomiting, or bacteremia. 

This patient had gallbladder disease and required a laparoscopic cholecystectomy. The patient tolerated the procedure well and was stable enough to have had it performed as ambulatory surgery. The patient did not meet MCG (Milliman Care Guidelines) criteria for admission for Gallbladder or Bile Duct Inflammation or Obstruction. The health care plan acted reasonably and with sound medical judgment. An 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 an inpatient admission is not substantiated.