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

Diagnosis: Chest Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

The patient is an adult male with a history of hypertension and substance abuse disorder. He presented with complaints of chest pain after cocaine and alcohol use. He reported suicidal ideation in the emergency department, but then subsequently denied the same. The patient's vital signs were stable. He was and afebrile, with oxygenation of 98%. His exam was unremarkable. His pertinent labs revealed potassium 2.9, troponin .01, and urine drug screen was positive for cocaine and alcohol. Chest x-ray revealed no acute disease. EKG (electrocardiogram) showed normal sinus rhythm. The patient's chest pain resolved with sublingual nitroglycerin. He was admitted and the plan of care include psychiatry consultation and CIWA (clinical institute withdrawal assessment) protocol.
On day #3, no further episodes of chest pain were noted. Ativan was not required. The patient was noted to not be psychiatrically cleared. The plan was for discharge when the patient was to be psychiatrically cleared. He was cleared for discharge on day #4.

The Inpatient Admission was not medically necessary.

This patient was admitted with chest pain after substance use. He reported suicidal ideation. The patient was hemodynamically stable and afebrile. EKG (electrocardiogram) and cardiac enzymes were not consistent with acute coronary syndrome. Diagnostic studies were remarkable for toxicology positive for cocaine and alcohol. He did not have signs or symptoms of withdrawal. These findings do not support an acute inpatient level of care. The MCG (Milliman Care Guidelines) Chest Pain criteria for inpatient admission are not met. The patient did not have respiratory distress, chest pain indicative of serious diagnosis other than coronary artery disease, or severe pain requiring acute inpatient management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Allergic Reaction.
Treatment: Inpatient admission.
The insurer denied Inpatient admission. 
The determination is overturned.

The patient is a female with a past medical history (PMH) of rheumatoid arthritis (RA) and postural orthostatic tachycardia syndrome (POTS) who was admitted with complaints of (c/o) generalized itching, throat itching, and body rash after increasing Plaquenil. Her vital signs were unremarkable. The physical exam was notable for a diffuse rash, Mallampati score at 1, with no tongue or lip swelling, and clear lungs. The patient was diagnosed with anaphylaxis and treated with epinephrine, intravenous fluids (IVF), H2 blockers, Benadryl, and steroids. The patient's symptoms worsened while in the emergency department (ED), requiring additional doses of epinephrine.
At issue is the medical necessity of Inpatient admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient admission was medically necessary for this patient.
This patient, with a known history of prior reactions to Plaquenil, presented to the ED with c/o generalized itching, throat itching, and body rash after increasing Plaquenil. The patient was monitored and treated aggressively with epinephrine, IVF, H2 blockers, Benadryl, and steroids. The patient's symptoms worsened while in the ED and after treatment, increasing the clinical risk for the need of monitoring, due to the risk of potential respiratory decompensation and compromise. A monitored inpatient bed is necessary for a patient with moderate to severe anaphylaxis who has not had substantial response to initial therapy, and progression of allergic reaction while undergoing treatment in the ED. Overall, this patient required close clinical monitoring for respiratory failure and worsening allergic reaction that could not have been safely performed at any other level of care than Inpatient. This patient had systemic symptoms for which a lower level of care is not considered appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dementia, gait instability, weight loss, major depressive disorder, and generalized anxiety disorder.
Treatment:  Consumer Directed Personal Care Assistance Services for a Total of 40 Hours per Week.

The insurer denied Consumer Directed Personal Care Assistance Services for a Total of 40 Hours per Week.  The denial is upheld.

The patient is an adult female who has dementia, gait instability, weight loss, major depressive disorder, and generalized anxiety disorder. The denial of an increase in consumer directed personal care assistance services for a total of 40 hours per week is being appealed. The health plan approved 10 hours per week. Uniform Assessment System evaluation completed four months ago shows modified independent cognition and functional status: total dependence with managing finances; extensive assistance with managing medications and phone use; limited assistance with housework; supervision with meal preparation and lower body dressing; and independent with bathing, personal hygiene, upper body dressing, walking, locomotion, toileting, bed mobility, and eating. She is continent of bowel and bladder. Appeal statements note the patient is unsafe. She leaves the stove on and gets lost in the street. She requires assistance to complete basic tasks due to mental illness. She does not remember to eat.

The proposed treatment is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. The denial of an increase in consumer directed personal care assistance services for a total of 40 hours per week is being appealed. The health plan approved 10 hours per week. Uniform Assessment System evaluation completed four months ago shows the patient requires assistance with managing finances and managing medications, phone use, and housework. Appeals statements note the patient is unsafe alone and needs supervision. Personal care services are not indicated for safety supervision, companionship, or when no tasks are being performed. The information provided does not support that the patient has functional needs that requires an increase in consumer directed personal assistance program (CDPAP) services from 10 hours per week to 40 hours per week.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: pain management services/ablation, 3 units. 
The insurer denied coverage for pain management services/ablation, 3 units. 
The denial is upheld. 

The patient has chronic lower back pain due to degenerative disc disease. The patient has a history of lower back pain, benign prostatic hyperplasia (BPH), gastroesophageal reflux disease (GERD), hyperlipidemia, migraines, nephrolithiasis, and obesity. The patient presented to the Pain Management physician's office for a follow up for lower back pain. The patient had a diagnostic bilateral medial branch block at the lumbar vertebrae (L)4-5 and L5-sacral vertebrae (S)1 facet joint. There was 80% pain relief for 8-12 hours after. The physician recommended the Intracept procedure to treat lower back pain, which is under review. 
The scientific evidence in peer-reviewed literature does not widely support a result of improvement in health outcome. 
"The basivertebral nerve (BVN) has been a recently discovered target as a potential source for vertebrogenic chronic low back pain (CLBP). Prior randomized controlled trials have demonstrated safety and efficacy of BVN ablation for vertebrogenic CLBP, but minimal data exists regarding BVN ablation's clinical effectiveness with broader application outside of strict trial inclusion criteria" (Macadaeg, K., et al. 2020). 
Medicare does not have National coverage determinations (NCDs) specifically for the use of the Intracept procedure in the treatment of chronic low back pain. Local Coverage Determinations (LCDs) do not exist at this time. 
U.S. Food and Drug Administration (FDA) gave 510(k) clearance for the INTRACEPT Intraosseous Nerve Ablation System. 
Since this procedure does not have established clinical efficacy, the patient is not a good candidate for intraosseous basivertebral nerve), pain management services/ablation, three units. 
It is not the best available treatment for this patient at this time. 
The adverse risks are increased over standard treatment/services. 
The procedure is associated with increased risks compared to standard treatment/ services. 
Intracept remains a procedure without established efficacy. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: pain management services/ablation, 3 units. 
The insurer denied coverage for pain management services/ablation, 3 units. 
The denial is upheld. 

This patient has chronic low back pain. He has tried heat and ice, a home exercise program, medial branch blocks and Mobic for pain. On magnetic resonance imaging (MRI), the physician notes that he has Modic type 1 and 2 changes at lumbar (L)3-L4, L4-l5 and L5-sacral (S)1. However, the MRI also shows Disc herniated at L3-L4 with L3 nerve root compression and L5 nerve root compression. There is no documentation of a surgical consultation. The request is for radiofrequency ablation (RFA) of the Basivertebral nerve (BVN). 

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. 

Conger et al (3) 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 (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. 

Urits et al (5) also commented on the need for more research on this promising technique: "reproducible large trials are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future." 

In sum, this procedure is NOT likely to be more beneficial than the standard therapies. 

In summary, the denial of pain management services/ablation, 3 units requested and coverage for the requested treatment 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: Kidney Stone
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with history of non-ischemic cardiomyopathy, obesity, and cirrhosis who presented to the emergency department (ED) with complaints of worsening right flank pain and nausea. The patient had prior history of an emergency department presentation ten days prior and was told he had colitis and a kidney stone and was placed on Augmentin (computed tomography demonstrated right distal ureteral calculus less than five millimeters). Repeat computed tomography scan obtained demonstrated unchanged right distal ureteral calculus, four millimeters, and mild right hydronephrosis. The patient's urinalysis revealed two white blood cells, one red blood cell, negative nitrite, and negative leukocyte esterase. The patient's labs revealed white blood cells (WBCs) 16 and creatinine 1.14. The patient was noted to be afebrile, hemodynamically stable, without need for oxygen. Emergency department recheck note states the patient was resting comfortably on the stretcher reporting still with mild pain. The patient was admitted for gentle intravenous hydration, ceftriaxone, Flomax, strain urine, morphine and Tylenol for pain. 
The next day, the patient's pain had resolved; he was afebrile with stable vital signs. Creatinine was 1.06 and white blood cells were 12.1. It was felt that the patient had likely passed the stone and he was discharged to home with outpatient follow-up. 
Acute inpatient admission was denied as not medically necessary as it did not meet Milliman Care Guidelines (MCG) criteria for admission.

The proposed inpatient hospital admission was not medically necessary.

This patient had a distal ureteral calculus with an unobstructed contralateral kidney, and no signs of urinary tract infection or sepsis (he was afebrile, hemodynamically stable, and had a negative urinalysis). His pain improved in the emergency department, he did not have persistent nausea and vomiting, and he did not have identified co-morbidities requiring acute inpatient admission for evaluation and management. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/dental issues
Treatment: Dental/Orthodontic Procedure/braces and monthly visits
The health plan denied the requested health service for braces and monthly visits as not medically necessary. The health plan's determination is overturned.

The patient in question is a male with a crossbite of anterior teeth 9, 10 and 11. He presents with a skeletal Class III malocclusion with moderate spacing in the maxilla and minor spacing in the mandible. He has a significant mandibular asymmetry with a posterior crossbite on the left. He is treatment planned for of 30-36 months of orthodontics combined with orthognathic surgery to address the crowding and crossbite
At issue is the medical necessity for the requested braces and monthly visits.

I overturn, in whole, the health plan's determination of medical necessity.

This patient presents with an anterior crossbite on teeth 9, 10 and 11, as well as severe spacing. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1,2,3] It appears the teeth in anterior crossbite are already exhibiting signs of abnormal wear.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem.
For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma. 
Treatment: inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

This is a child with a history of asthma and one previous admission to the hospital for asthma. There were three emergency room (ER) visits for asthma in the past 6 months. She had a cough and shortness of breath for 1 day prior to admission. She had been administered 5 doses of albuterol in the home with no improvement in her cough, so her mother brought her to the emergency room (ER) for additional treatment. 

On presentation she was noted to be in respiratory distress with increased work of breathing. She was noted to have had 5 episodes of post tussive vomiting. On physical examination she was noted to have prolonged expiration and bilateral wheezing. She was treated with 3 doses of duoneb and decadron and her wheezing was noted to improve. A chest X-ray was clear, and a blood gas was obtained which showed a pH (potential of hydrogen) of 7.35 and a pCO2 (partial pressure of carbon dioxide) of 40.7.  In view of the poorly controlled asthma with an elevated pCO2 over 40 the decision was made to admit the child to the hospital because of concern for risk of progression to respiratory failure related to CO2 retention. The diagnosis for the admission was status asthmaticus with a plan to continue albuterol every 3 hours. 

The patient was treated appropriately in the emergency room (ER) for a cough, wheezing and tachypnea. She was in acute respiratory distress when she arrived, the blood gas was concerning for CO2 retention which indicated that her asthma was poorly controlled. She had received 5 doses of albuterol in the home with no improvement and she had 5 episodes of post tussive (cough) vomiting. The decision to admit to the hospital was consistent with the standard of care for a case of status asthmaticus with an elevated pCO2 level of 40.7. The plan was to continue albuterol every three hours in the hospital, and this could not have safely been administered in the home. The child was not stable enough to be discharged home safely and admission was appropriate and consistent with the standard of care. 

Based on the above, the insurer's denial must be overturned. 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 the full hospital admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease)
Treatment: Linx Procedure (43284)
The insurer denied: Linx Procedure (43284)
The denial is upheld.

The patient is an adult female with a many-year history of symptomatic GERD (gastroesophageal reflux disease). She is treated with Carafate, pantoprazole, and famotidine with 
minimal relief. Endoscopic studies indicate normal motility and acid exposure with a DeMeester score of 29. Due to unresponsiveness to medical management, she was deemed to be a good candidate for surgical management of GERD (gastroesophageal reflux disease).

The health plan should not cover the LINX procedure.

The patient is a good candidate for surgical management of her reflux disease. This could be done as a fundoplication with hiatal hernia repair or magnetic sphincter augmentation. Review of the literature indicates that newer augmentation approaches do not provide improved outcomes for acid relief or dysphagia, and unclear responses for vomiting. As such, fundoplication with hiatal hernia repair is a satisfactory surgical option.
Review of multiple studies show no reliable advantage with respect to symptom relief, medication usage, dysphagia with magnetic augmentation relative to a standard surgical approach.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease)
Treatment: Linx Procedure (43284)
The insurer denied: Linx Procedure (43284)
The denial is overturned

The patient is an adult female with reflux. She has normal motility study, but pH (potential of hydrogen) study shows DeMeester score of 29.2. Upper GI (gastrointestinal series) showed mild reflux with normal endoscopy without signs of Barrett's, but 3-centimeter hiatal hernia was present. The patient has tried medications with little relief. The request for laparoscopic hiatal hernia repair 
with LINX device for gastroesophageal reflux disease was denied coverage by the health plan, because it was deemed investigational. The denial is being appealed based on current literature.

The health plan should cover the LINX procedure.

There is significant amount of literature with support from multiple societies on the use of this device for treatment of GERD (gastroesophageal reflux disease). Guidelines repeatedly state that the need for prospective, long-term, randomized studies for this disease is not realistic. Randomized studies showed that this device is better than conservative treatment with medications. Other prospective studies showed similar outcomes to laparoscopic Nissan fundoplication with low retrieval rates.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical chest pain. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male patient with a past medical history (PMH) of coronary artery disease (CAD) status/post (s/p) left anterior descending (LAD) stent, heart failure with reduced ejection fraction (HFrEF) status/post (s/p) implantable cardioverter defibrillator (ICD), diabetes mellitus type 2 (DM2), and chronic kidney disease (CKD) who was admitted with complaints of (c/o) a cough and sore throat associated with atypical chest pain. His vital signs were unremarkable. The physical exam was notable for no respiratory distress, rales. Imaging studies included a chest x-ray (CXR) which showed no acute pathology. An electrocardiogram (EKG) showed a known left bundle branch block (LBBB) without (w/o) ischemic changes. The patient was diagnosed with a congestive heart failure (CHF) exacerbation and treated with intravenous (IV) diuresis. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care. 

The admission was not medically necessary at an acute inpatient level of care. This patient with a known history of heart failure presented to the emergency department (ED) with a cough and sore throat associated with atypical chest pain. The patient was not in acute distress and was hemodynamically stable. Additionally, the patient was not severely compromised, did not have an elevated blood urea nitrogen, low admission systolic blood pressure, significantly elevated creatinine, cardiac ischemia, airway instability, cardiac arrhythmias requiring continuous intravenous (IV) intervention, or inadequate systemic perfusion, nor did the patient require vasodilator therapy. Finally, the patient's Ottawa Heart Failure Risk Scale (OHFRS)-Heart Failure Risk Score was 0, indicating a low-risk for serious adverse events, and the patient's Get With The Guidelines-Heart Failure (GWTG -HF) score was also consistent with low-risk in-hospital all-cause mortality. Overall, this patient was monitored, received intravenous (IV) diuresis and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bone Cancer
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This is an adult male with arm pain. He has a history of bone cancer. He was admitted to the hospital to undergo surgery (preoperative work-up) (proximal humeral joint replacement). He did not have the operation and left against medical advice (AMA). The patient was status post biopsy 4 months ago showing an osteosarcoma. He had multiple underlying medical conditions.

The proposed treatment was not medically necessary.

The documentation shows admission was for preoperative assessment. The patient has an extremely complex medical condition with several system pathologies. He required subspecialty consultation and extensive testing prior to his joint replacement. However, there was no report of an unstable condition to warrant an admission. These services could have been completed as outpatient over a period of day. The patient's pain level was tolerated. There was a report of planned surgical date 4 months ago. The patient's vital signs were stable. He had no evidence of injection nor bleeding. He had no active medical problem to require urgent evaluation, admission and treatment. His leaving the hospital was taken into consideration. 
There were no extenuating circumstances to substantiate an acute level admission. Milliman Care Guidelines (MCG) have not been fulfilled.