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

Cardiac
Inpatient hospital

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

The patient is a male who presented to the emergency department (ED) complaining of a one hour episode of rapid heart rate two weeks prior. He also reported an episode of chills the day prior to presentation. His medical history was unremarkable. In the ED, he had no acute complaints. His blood pressure was 202/108 with a heart rate of 100 beats/minute. His room air oxygen saturation was 99%. An electrocardiogram showed sinus rhythm with left bundle branch block. No prior tracings were available for comparison. His serum troponin level was normal and remained normal when re-measured. His brain (or B-type) natriuretic peptide (BNP) level was normal. Chest X-ray showed no acute pathology. While in the ED he remained in sinus rhythm with occasional to frequent premature ventricular complexes (PVCs). 

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented complaining of an episode of palpitations two weeks prior. He had no acute complaints. His rhythm was sinus with left bundle branch block (LBBB) and occasional to frequent premature ventricular complexes (PVCs). While left bundle branch block may be an indicator of underlying heart disease it is also seen in patients without other cardiac abnormalities. In and of itself it does not require any treatment. In patient's with left ventricular dysfunction it may be an indication for biventricular pacing. However, this is considered an elective procedure and, in this case, was not an indication for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female patient with a history of alcohol abuse and bipolar disorder presented to the emergency department with alcohol withdrawal symptoms. She reported accidentally drinking multipurpose cleaner. She denied suicidal ideation. The patient's vital signs were stable. The respiratory rate was 16. The heart rate was 92. The patient's exam was unremarkable. Pertinent labs include potassium 3.4 and alcohol 364. Electrocardiogram (EKG) noted normal sinus rhythm and no acute changes. She was admitted with alcohol withdrawal. Plan of care included Clinical Institute Withdrawal Assessment (CIWA) protocol. On day # (number) 3, she was noted to be having tremors. On day #4, she signed out against medical advice.

The requested health service was not medically necessary.

This patient was admitted for alcohol withdrawal. The patient was hemodynamically stable and afebrile. She did not have tachycardia, vomiting, delirium, or seizures. Labs were remarkable for elevated alcohol level. The patient was admitted with plan for diuresis and Clinical Institute Withdrawal Assessment (CIWA) protocol. The patient was clinically stable and did not have findings of severe alcohol withdrawal. The Milliman Care Guidelines criteria for Substance-Related Disorders, Adult for inpatient admission is not met. The patient did not have alcohol withdrawal with elevated risk due to history of delirium due to alcohol or sedative withdrawal, history of repetitive seizures due to alcohol or sedative withdrawal, intrinsic seizure disorder (epilepsy), pregnancy, or other significant medical history. The patient did not have an inadequate response to pharmacotherapy in the emergency department or other appropriate lower level of care, and her condition was not such that a lower level of care was not feasible or appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back Pain
Treatment: Intracept Procedure
The insurer denied Intracept Procedure.
The determination is upheld.


This is a male patient with a chief complaint of chronic low back pain. His lumbar pain is cramping aching with radiating and burning pain in the left buttock, down the thigh and calf. The pain is aggravated by standing and walking, and improved partially by chiropractic manipulation and a Medrol dose pak. The patient underwent lumbar transforaminal epidural injections, multiple facet injection and two radiofrequency ablations with significant pain relief. The physical exam (PE) is significant for limited lumbar spine range of motion (ROM), and positive facet loading tests. A magnetic resonance imaging (MRI) report documented disc bulge and facet arthropathy at lumbar (L) 3/4 and L4/5 levels, discogenic degenerative endplate changes at L4/5, however, discitis/osteomyelitis may have a similar appearance. The provider recommended blood work to rule out discitis and the Intracept procedure at L5/sacral (S)1.
At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. This patient has low back pain with radiating pain down to left leg. He responded to prior lumbar transforaminal epidural injections, multiple facet injection and two radiofrequency ablations. The PE indicated positive facet loading tests. MRI report documented disc bulge and facet arthropathy at L3/4 and L4/5 levels, and discogenic degenerative endplate changes at L4/5 with similar appearance to discitis. Truumees's study supported the efficacy of Intracept procedure. However, patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. (1) From reviewing the medical records and current clinical studies, it is unlikely this patient will benefit from the Intracept procedure at L5/S1.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back Pain
Treatment: Intracept Procedure
The insurer denied Intracept Procedure.
The determination is upheld.

This is a male patient who has complaints of chronic low back pain involving the lumbar spine with radiation to left buttocks down the thigh and calf. The lumbar spine pain is aggravated by all movement and is constant. Medications have included diclofenac, medrol dose pak, muscle relaxants, and over-the-counter (OTC) medications. Magnetic resonance imaging (MRI) shows Modic changes in the lumbar (L) 5/ sacral (S) 1 vertebral bodies, which is the suggested cause of the patient's chronic vertebrogenic low back pain. At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to Becker, et.al : "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)."
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial.
As cited above, Becker. et.al trial indicated only a 17 patient observational study.
These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures.
According to Smuck M , et. al " Accordingly, longer-term follow-up may be needed to observe changes in opioid behaviors as demonstrated by a secondary analysis of data from the previous sham-controlled randomized controlled trial (RCT) of basivertebral nerve (BVN) ablation that showed opioid reduction in the subgroup reporting improvements in pain during long-term follow-up."
Long term outcomes have not been elucidated demonstrating health outcomes, pain, and disability measures.
In addition, no United States guidelines based on research recommend this treatment. The proposed health service or treatment Intracept procedure 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: Low back Pain
Treatment: Intracept Procedure
The insurer denied Intracept Procedure.
The determination is upheld.

This is a male patient with a chronic history of low back pain. The pain can be as high as 6 out of 10 and severely impacts the patient's activities of daily living. Prior treatments have included medications, and injections, as well as therapy. Magnetic resonance imaging (MRI) of the lumbar spine reported Modic changes at disc spaces lumbar L) 5-sacral (S) 1. The Intracept procedure is under review.

The proposed health service or treatment Intracept procedure 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 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 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 Intracept procedure 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: Medical necessity
Decision: Upheld

Diagnosis: Bilateral lower extremity claudication
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female for whom an inpatient hospitalization is under review. She presented with bilateral lower extremity claudication and for an elective lower extremity angiogram and intervention. She underwent a successful and uncomplicated lower extremity angiogram and intervention of the right superficial femoral artery. The patient's vital signs were essentially normal. Her oxygen saturation was normal. She was in no acute distress. Creatinine was 0.58.

The Inpatient admission was not medically necessary.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post-procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, acute lower extremity ischemia, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to a lower level of care, has not been established as standard of care toward improved percutaneous intervention or overall peripheral vascular disease (PVD) outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myelomeningocele
Treatment: MRI (magnetic resonance imaging) of the lumbar spine
The insurer denied: MRI (magnetic resonance imaging) of the lumbar spine
The denial is upheld.

The patient is school aged female with a history of a myelomeningocele. She had an initial repair 5 years ago in Honduras. She had an infection and had a second surgery. The second surgery was performed by a neurosurgeon 2 years ago. She developed problems with urine and stool continence after that second surgery. The notes from her neurologist (initial note dated 10 months ago) state she underwent magnetic resonance imaging (MRI) of the lumbar spine last year. The report was not available. The notes state there would be an attempt to obtain the notes from the surgeon. The plan included recommendations to see a urologist, gastroenterologist, orthopedics, and rehabilitation. A voiding urethrocystography showed findings consistent with a neurogenic bladder. The follow-up visit was 4 months ago. The documented neurological exam was unchanged between the two visits. The magnetic resonance imaging of the lumbar spine report was not available at that time, and an order for magnetic resonance imaging of the lumbar spine was placed. There were no notes from the surgery or post-operative exam or follow-up exams or imaging by the neurosurgeon. Coverage for magnetic resonance imaging of the lumbar spine was denied by the health plan as not medically necessary. The plan denial letter stated magnetic resonance imaging of the lumbar spine was already approved last year and requested notes showing the results from that image. This decision was appealed with a form stating magnetic resonance imaging of the lumbar spine was necessary. No further information was provided. This review is in regard to magnetic resonance imaging of the lumbar spine request.

The requested health service is not medically necessary.

The case involves a patient with a myelo-meningocele who underwent two separate surgeries. The notes include evaluations by a neurologist who evaluated the patient in 10 months ago and 4 months ago. The notes refer to a prior lumbar spine magnetic resonance imaging (MRI) from last year. The notes do not include documentation of the surgery or post-operative course or follow-up surgical evaluations. The notes do not include results of past imaging. The notes do not state the patient had a clinical decline or new symptoms requiring follow-up imaging (1, 2). The plan denial referred to a study that was approved the year prior. The appeal did not include information in relation to magnetic resonance imaging from the year prior or information related to the follow-up care the patient had at that time. Thus, necessity for another repeat magnetic resonance imaging of the lumbar spine cannot not be established. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Mental Health
Mental health inpatient 

Diagnosis: schizoaffective disorder
Treatment: inpatient mental health
The insurer denied Continued Stay for Inpatient Mental Health Level of Care 
The health plan's determination is overturned in part. 

This case involves an adult male with a longstanding diagnosis of schizoaffective disorder, bipolar type versus schizophrenia and bipolar disorder. The patient presented with symptoms of psychosis and agitation after stopping his medication. He was kicked out of the shelter where he was staying due to aggressive behavior towards others. He was not sleeping and was pacing which prompted his presentation to the emergency department. He was evaluated, medically cleared, and admitted to acute inpatient level care. He had been discharged from another inpatient psychiatric facility recently after a two-week stay.

Continued Stay for Inpatient Mental Health Level of Care for an additional 54 days was medically necessary. However, after this time, the patient no longer required the inpatient mental health level of care. 

In this case scenario, the continued inpatient level services were necessary in view of the continued acuity and risk for aggressive behavior and need for continued inpatient level structure and monitoring. The patient had not reached a level of stability that he could have been safely or effectively managed with lower-level services. The patient continued to need the intensity of services, structure, and monitoring of an inpatient setting.
However, after the additional time, it was not medically necessary for this patient to have 24-hour monitoring in an acute care setting in view of his relative lack of impulsive behaviors, diminished symptoms of psychosis, and improvements in mood and sleep and daily functioning. There were no general medical issues or co-occurring substance use disorders complicating this case that would have required continued inpatient level services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain. 
Treatment: Pain injections (64479 x 1, 64480 x 1). 
The insurer denied pain injections (64479 x 1, 64480 x 1). 
The determination is upheld. 

This is a patient with a request for transforaminal cervical epidural steroid injection at the left cervical (C) 4-C5 and C5-C6. This was denied by the health plan, as injections into the neck must show that non-particulate steroid medication would be used in the provider did not submit this information despite requests. The provider is appealing this determination and stated that they submitted additional clinical notes, noting that the patient is being treated for an acute flareup of cervical radiculopathy due to dynamic foraminal stenosis exacerbated by motion and weight-bearing. The provider notes they would be using Kenalog for the injection. 
The patient was seen for a follow-up visit with a history of pain in multiple body parts including the cervical spine. It was noted the visit was completed via telemedicine. The neck pain is rated at 10/10 with medications and 9/10 without medications and starts in the neck predominantly radiating to the bilateral arms with weakness and tremors, severe numbness and tingling in both hands. The patient reports symptoms are increasing. The patient has previously undergone multiple cervical epidural injections, most recently when the patient underwent a C7 - thoracic (T) 1 interlaminar injection reporting 90 percent (%) pain relief lasting 5 months and as a result could sleep better. There is reference to multiple imaging studies and electrodiagnostic studies. Current medications include buprenorphine, Tylenol, ibuprofen, cyclobenzaprine, nortriptyline, Horizant. The plan was to continue medications. The patient was recommended for a cervical brace to reduce pain by providing transient therapeutic traction restricting mobility of the neck to support weakened spinal muscles. It was recommended that the patient undergo a repeat cervical inner laminar epidural injection at C7 - T-1 with fluoroscopic guidance. At issue is the medical necessity of pain injections. 
The requested health service/treatment of pain injections is not medically necessary for this patient. The patient is noted to have a history of chronic neck pain with radicular symptoms and has had previous and  multiple prior cervical epidural injections, most recently when the patient underwent a C7 - T-1 interlaminar injection with reports of 90 percent (%) pain relief lasting 5 months and could sleep better. There was decreased sensation at the left C6 and C7 distribution. However, the provider references multiple imaging studies and electrodiagnostic studies but none of the official reports were submitted for review to corroborate radiculopathy. There is no documentation showing the patient has completed any recent active conservative treatment for the flare up of symptoms. Additionally, the provider stated they would be using Kenalog (triamcinolone acetonide), which is a particulate steroid and would not be supported when performing cervical epidural injections. Medical necessity is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Crohn's disease, cardiomyopathy, depression.
Treatment:  Consumer Directed Personal Assistance Services.

The insurer denied Consumer Directed Personal Assistance Services.  The denial is upheld.

This adult female patient has a history of Crohn's disease, cardiomyopathy, sleep apnea, chronic renal failure, asthma, anxiety, and depression. She lives alone. The denial of Consumer Directed Personal Assistance Services is being appealed. Uniform Assessment System (UAS) evaluation completed 3 months ago shows independent cognition and functional status: independent with activities of daily living (ADLs), except limited assistance with meal preparation. The patient's daughter provides informal support. The patient has frequent bowel incontinence. A letter from her Provider reports the patient has limited mobility. A letter from the Ambulatory Care Center reports the patient has multiple conditions. She has frequent diarrhea. She sees multiple specialists. A letter from her Social Worker reports the patient receives individual psychotherapy and medication management of major depressive disorder. Home care services are requested due to her depression and medical problems. A statement from the patient reports she has uncontrolled bowel movements due to Crohn's disease, breathing problems due to chronic obstructive pulmonary disease (COPD), leg weakness, body aches, heart racing, and dizziness. She requests assistance with home chores and using the stairs.

The requested health service is not medically necessary. 

Consumer Directed Personal Assistance Services (CDPAS) provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs). This patient has several chronic conditions. The denial of Consumer Directed Personal Assistance Services (CDPAS) is being appealed. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient is independent with activities of daily living, except limited assistance with meal preparation. She receives informal support from her daughter. Appeal letters report the patient has several symptomatic chronic medical conditions and needs assistance with home chores. Based on the Uniform Assessment System evaluation and appeal statement, the patient does not have functional needs requiring Consumer Directed Personal Assistance Services. These services are not indicated for management of medical conditions or when no tasks are being performed. The proposed Consumer Directed Personal Assistance Services is not indicated.