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

Diagnosis: Asthma
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission
The denial is upheld

This is a patient with a history of Asthma who presented to the emergency department (ED) with complaint of shortness of breath, fever, chills, a headache and some productive cough. The patient had been seen in another facility the previous day and was released after treatment with nebulizers and steroids. Her symptoms continued so she was referred to the ED by her primary physician doctor.

Upon arrival to ED, her vital signs at presentation were Temperature- 99.4F (Fahrenheit), Heart Rate- 120, Respiratory Rate- 21, and a Blood Pressure of 100/59 mm Hg (millimeters of mercury). The patient was in no apparent distress. There was only mild wheezing during the lung exam, and she was alert and oriented x 3.

Her lab results were as follows:
Her white blood count was 7K (thousand), and her Hemoglobin-Hb was 11.7,
Her electrolytes were within normal limits except her potassium was low at 3.2.
Her blood urea nitrogen/Creatine were within normal limits.
The Arterial Blood Gas was 7.45/30/76/20. She was Influenza A positive. The 
chest x-ray did not show any acute infiltrates.

The patient was admitted to the hospital with a diagnosis of having Asthma Exacerbation and Influenza.

She was initially placed on IV (intravenous) Steroids, bronchodilators via nebs (nebulizers), Rocephin, and Azithromycin.

The patient was placed on a BiPAP (Bilevel positive airway pressure) 10/5 and FIO2 (fraction of inspired oxygen) at 30% briefly for less than an hour. At the patient's request it was taken off and she was in no apparent distress. She was saturating at 95% on room air.

As per the history and physical examination, she was afebrile and hemodynamically stable. The respiratory rate was 18, oxygen sats (saturation) were 95% on room air and her lungs were clear. 

This patient was admitted and treated with Tamiflu, Doxycycline, Steroids and BD (bronchodilators).

This patient remained stable after admission and was eventually discharged after a few days on oral medications.

This patient did not need acute hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could have been up to 48 hours. She had mild wheezing on exam which cleared after antibiotics. She was not hypoxic and was saturating 95% on room air. She was on a BiPAP for about 50 minutes and remained stable on room air after it was removed. She was tolerating medication. Her chest x-ray was clear of pneumonia or effusion. This patient could have been discharged on oral medications after initial treatment and management in the emergency department.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pilonidal cyst
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is upheld

This is a patient with a past medical history significant for a pilonidal cyst who presented to the emergency department with complaints of a recurrent pilonidal cyst on his bilateral buttocks and inter-gluteal cleft. 

Vitals on presentation included: Temperature 98. F (Fahrenheit) , Blood Pressure 118/89, Pulse 100, Respiratory Rate 18, and oxygen (O2) saturation 100% on Room Air. Laboratory results included the following: white blood cell count (WBC)12.4, HGB-11.9, HCT (hematocrit)-36, creatinine-0.8, and glucose-100.

The patient was started empirically on antibiotics (vancomycin, cefepime, metronidazole). A computed tomography (CT) scan of the pelvis showed a 3.5 x 3.2 x 7-centimeter dense area within the subcutaneous soft tissue posterior to the sacrum and coccyx. Surgery was consulted and they recommended an incision & drainage procedure. The patient refused. He remained afebrile and hemodynamically stable. He was discharged to continue outpatient management on oral antibiotics. 

Pilonidal disease is a common condition of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks. This patient presented with a recurrence of lesions in his buttocks area. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory results. There was no evidence of a disseminated infection. The patient required non-emergent surgical management generally performed as an outpatient. Based on the above findings, the patient met criteria for observational level of care. He did not meet criteria for an acute inpatient hospitalization.  

Prior determination of denial of coverage for hospital services is upheld.

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Nerve Ablation
The health plan denied the requested procedure as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with complaints of low back pain. The patient has had pain for over one year. Prior treatments have included activity modification, medication management, as well as lumbar injections. The patient has had multiple injections. His pain is rated as high as 7 out of 10. Activities of daily living are restricted. A magnetic resonance imaging (MRI) of the lumbar spine demonstrated degenerative changes at (lumbar) L4-5. The patient is noted to have vertebrogenic low back pain.

At issue is whether the proposed health service or treatment of Intraosseous Nerve Ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service is upheld, in whole.

The proposed health service or treatment Intraosseous Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain.

There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in a decreased Oswestry Disability Index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.

Given the above, the proposed health service or treatment of Intraosseous Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Nerve Ablation
The health plan denied the requested procedure as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with a history of chronic low back pain secondary to degenerative disc disease in the lumbar spine as per a magnetic resonance imaging (MRI). He was treated with time and rest. The appeal documentation stated that the patient was not prescribed non-steroidal anti-inflammatory drugs (NSAIDs) or opiates because of potential side effects and abuse. He was also treated with lumbar radiofrequency denervation. The treating physician recommended the Intracept procedure.

At issue is whether the proposed health service or treatment of Intraosseous Nerve Ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service or treatment is upheld, in whole.

No, the proposed health service or treatment of Intraosseous Nerve Ablation would not be likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The limitation of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Radiculopathy

Treatment is outpatient procedure (22630 x 1 and 22633 x 1) back surgery

The insurer denied coverage for outpatient procedure (22630 x 1 and 22633 x 1) back surgery
 
The denial is modified

A lumbar magnetic resonance imaging (MRI) report notes progressive degenerative changes since the last MRI (magnetic resonance imaging) with Modic endplate changes. At L(lumbar) 4-5-disc bulge and superimposed left foraminal/far lateral disc protrusion that contacts the exiting left L4 nerve root, and the lateral disc herniation is new. No significant spinal canal stenosis.

An office note from Orthopedics notes that she is a former smoker, noting that she quit. She quit the day her surgery was denied. She knows she must be nicotine free for 6-8 weeks. Her pain is rated 10/10 and radiates to the bilateral lower extremities posteriorly with intermittent numbness and tingling. She takes gabapentin and diclofenac. She had failed most conservative treatments and has difficulty with activities of daily living. Her exam notes decreased peroneal strength 4/5 on the left with decreased sensation of the posterior thigh, leg and plantar foot on the right and left. She has abnormal Achilles reflexes and a positive straight leg raise on the left. The note then states that she has been nicotine free for greater than six weeks and she was agreeable to undergo an L4-5 transforaminal lumbar interbody fusion with posterior decompression instrumented fusion. 

A lumbar x-ray noted no significant motion on flexion/extension. Severe disc space narrowing with endplate degenerative changes and osteophyte formation at L4-5, multilevel facet arthrosis most prominent at L4-5 and L5-S(sacral)1. 

There is documentation that the patient stopped smoking and had continued to do so up until the last office note. There is the recent appeal note that states she is not smoking.  Her complaints and exam are consistent with imaging that shows foraminal and far lateral recess stenosis on the right with L4 nerve root involvement.

Surgery for spinal stenosis consists of either decompression alone, or decompression with spinal fusion. Decompression by laminectomy is the treatment of choice for central or lateral recess stenosis. On the other hand, fusion is required if foraminal stenosis is present. (2)

The health plan acted reasonably in part. This reviewer agrees that both codes 22630 and 22633 are mostly the same. The durgery was denied for the patient smoking. However, the record documents the patient quit smoking. On appeal, the surgeon is requesting 22633. Any other codes requested are not the subject of this particular appeal.

The insurer's denial of coverage for outpatient procedure (22630 x 1 and 22633 x 1) back surgery is modified. Medical Necessity is substantiated for 22633 X1.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic cholecystitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female admitted for chronic cholecystitis, and revision of her gastric bypass. The patient was admitted overnight. She was discharged on the next day.

No, the proposed inpatient hospital admission was not medically necessary.
There are no qualifying criteria in the operative report and documentation that necessitates inpatient admission. The patient was discharged home the next day tolerating a bariatric diet. It is documented in the appeal letter about the patient's bradycardia; however, in the medical records, there was no follow up for the patient's bradycardia or notes suggesting that it was improved. The rest of the vital signs were stable throughout the stay as documented in the chart. There was nothing documented in the chart that necessitated inpatient level of care after this procedure as most gallbladders that are not actively infected can be discharged and the patient tolerated her diet after bypass revision with hiatal hernia repair.  Recent meta analysis by Xiong et al. that robotic cholecystectomies can be completed at day surgery centers effectively without an increase in morbidity or mortality.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The patient could have been admitted at a lower level of care
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Short Stature
Treatment: Genotropin
The insurer denied: Genotropin
The denial is: Overturned

The patient is a male diagnosed with idiopathic short stature (ISS). This request is for Genotropin. His growth hormone (GH) stimulation test with clonidine and arginine peaked at 19. Several months later, his testes were 5 cubic centimeters (cc) bilaterally and pubic hair was at Tanner 2. The subject under review is the medical necessity for Genotropin.

The requested Genotropin is medically necessary for this patient.
The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below.
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society[1], the Lawson Wilkins Pediatric Endocrinology Society[2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists[4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 standard deviations (SD) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low Insulin-like Growth Factor 1 (IGF1) or Insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10 nanograms/milliliter (ng/ml).
The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDs less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."[10-13]
The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria.
The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting, and abdominal pain
Treatment: Inpatient emergency admission
The insurer denied coverage for inpatient emergency admission
The denial is upheld

The patient had a history of morbid obesity and had a sleeve gastrectomy. She required a readmission after the procedure for nausea and vomiting. She again returned to the Emergency Room (ER) about a month later with similar symptoms. She now presents with nausea, vomiting, and abdominal pain. She was afebrile and the vital signs were stable. The abdominal exam was benign. An abdominal computed axial tomography (CAT) scan showed no complications from the surgery. There was no evidence of bowel obstruction. The potassium was 2.7. Intravenous (IV) hydration with potassium replacement was given. She was given a Bariatric diet and was able to tolerate it. 

Milliman Care Guideline (MCG) Clinical indications for admission for Dehydration (MCG M-123) include hemodynamic instability, acute renal failure, altered mental status, inability to maintain oral hydration after observation care, and severe electrolyte abnormalities. The electrolyte abnormality may be a potassium less than 2.5 that is not corrected to near baseline after observation care or a potassium less than 3 with cardiac findings. The patient did not have these conditions. 

Clinical indications for admission for Vomiting (MCG M-370) include having a severe metabolic derangement, hemodynamic instability, acute renal failure, or severe electrolyte abnormality such as a potassium under 2.5 or a sodium less than 130 that does not correct to near baseline despite observation treatment. The patient did not have these conditions. Her electrolytes improved with treatment. 

This patient had vomiting resulting in electrolyte abnormalities. However, both the hypokalemia and hyponatremia were able to be corrected. IV hydration and antiemetics could have been given with observation care. She did not have acute renal failure. She required dietary changes to a Bariatric diet, but this could also have been done with observation status. She did not meet MCG criteria for acute care for either Dehydration or Vomiting. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine myomas
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.

Uterine myomas are the most common benign tumors of the female genital tract. Surgery is the mainstay of treatment. Minimally invasive treatment approaches lead to less postoperative pain, reduced blood loss, fewer complications, decreased hospital stay and costs, and faster recovery time. A low preoperative hemoglobin or hematocrit, longer operative time, and a later surgery end time have been associated with an overnight stay. [1, 2] The size and diameter of myomas may also play a role in an extended hospital stay. The patients who were admitted have been shown to be more likely to require blood transfusions. [1]

Per clinical documentation, the patient underwent a laparoscopic. Pre-operative hemoglobin was noted to be 8.6g/dL (grams per deciliter). The hemoglobin after the procedure dropped to 7.7g/dL and then further to 6.9g/dL. The patient was transfused and discharged when the hemoglobin stabilized. Per Milliman Care Guidelines (MCG) criteria, goal length of stay is ambulatory or 2 days postoperative. Inpatient admission is warranted in patients in which necessary postoperative care cannot be performed in other than inpatient setting (i.e., blood transfusion). [3] Per provided clinical documentation, the requested inpatient admission was medically necessary and in the best interest of the patient. 

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 an inpatient admission is substantiated
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral palsy, epilepsy, chromosomal abnormality, GERD (gastroesophageal reflux disease), and developmental delays
Treatment: Medical Equipment (standard wheelchair and accessories - K0005x [times] 1, K0040x1, E0971x2, E0961x2,  E0955x1, E2613x1, E2607x1, K0038x1, E0960x1)
The insurer denied medical equipment (standard wheelchair and accessories - K0005x1, K0040x1, E0971x2, E0961x2,  E0955x1, E2613x1, E2607x1, K0038x1, E0960x1).
The denial is overturned.

The patient is a female child with cerebral palsy, epilepsy, chromosomal abnormality, GERD (gastroesophageal reflux disease), and developmental delays. The patient has been receiving skilled physical therapy services due to muscle weakness and decreased tone. The patient exhibits poor balance and has been described to exhibit an "awkward, assisted gait pattern," ambulating short distances with posterior rolling walker. The patient has been evaluated for seating immobility due to the fact that this patient has been reported to be not a functional ambulator. The patient has been recommended the Quickie Manual Zippie Zone wheelchair with accessories (K0005x [times] 1, K0040x1, E0971x2, E0961x2,  E0955x1, E2613x1, E2607x1, K0038x1, E0960x1).

The initial request was denied coverage by the health plan due to lack of information in relation to home and community access. Additional information has been provided by the seating and mobility specialist pointing out specifically the accessibility both at home and community, including school.

The requested health service is medically necessary.

The patient is a female child with cerebral palsy, mixed tone, developmental delays, and epilepsy. The patient is a limited community ambulator with assistive device and history of seizures. The patient attends school and does not have significant barriers for wheelchair access. The patient has been receiving timely and appropriate health care and is compliant with clinical care.

Therefore, given the above, the health plan should cover the requested health service.