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

Diagnosis: Fever, chills, abdominal pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a history of human immunodeficiency virus (HIV) who was stated as compliant with medication. He presented to the emergency department with complaints of (c/o) left (L) sided abdominal and chest pain since being discharged from another hospital. At that hospital, he was admitted with multiple gunshot wounds, he underwent surgery. He had bilateral chest tubes, removed prior to his discharge from that facility.
At the current emergency department (ED) he complained of two days of worsening abdominal pain, chest pain, and chills.  
He was diagnosed with sepsis and a surgical site infection, cultured, started on Zosyn and Vancomycin. A computed tomography (CT) scan of the chest, abdomen, pelvis was ordered and a surgery consult was ordered. 

The patient was seen by cardiothoracic (CT) surgery who felt that the CT findings were most consistent with (c/w) post-inflammatory changes and interventional radiology (IR) also agreed there was no indication for a drainage procedure. 
The patient improved on antibiotics and remained afebrile and hemodynamically stable. Surgery was consulted and stated a plan to remove the abdominal incision staples and JP drain on day 14 post-operative (post-op). However, patient left against medical advice (AMA).
At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary for this patient.
This patient was status/post (s/p) removal of bilateral chest tubes, but was discharged with staples in abdominal incision, and a JP drain(Jackson-Pratt). He met sepsis criteria on presentation in the ED, with marked leukocytosis, evidence of a surgical site infection, and also concern for an intra-abdominal abscess collection and loculated pleural effusion. 
This patient had numerous medical and surgical issues that required close monitoring, and the clinical scenario and physical findings would likely put him at increased risk for a complicated course. Sound and astute medical judgement in assessing this patient would lead to the expectation that he would require inpatient level of care (LOC) for several days, until evidence of a resolving infection, and until such time as the patient could be safely transitioned to oral antibiotic therapy. This patient did require inpatient LOC.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Disorder/plantar fasciitis
Treatment: Shoe inserts L3000x2
The health plan denied the requested shoe inserts L300x2 as not medically necessary.
The health plan's determination is upheld.

The patient is a male who presented for evaluation of his heel pain. He has a history of plantar fasciitis in the past about 3-4 years ago and was treated with conservative care, including custom molded orthotics with relief. The patient has pain on palpation of his medial tubercle of his calcaneus. The patient was diagnosed with plantar fasciitis. He was recommended stretching, icing, supportive shoes gear and custom molded orthotics.
The issue is the medical necessity for the requested health service/treatment of shoe inserts (foot orthotics, custom).

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

The requested health service/treatment of shoe inserts are not considered medically necessary for this patient. The patient had a flare up of his plantar fasciitis. Custom molded orthotics should not be considered a first line treatment. Due to this being a flare up, the patient should exhaust a reasonable amount of conservative care before recommending custom molded orthotics. Thus, the custom orthotics are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol withdrawal
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

This case involves a man with alcohol abuse who was admitted to the hospital with hematemesis. He also reported rectal bleeding, with blood on the toilet paper. The patient continues to drink vodka and beer daily. Similar admissions for prior symptomatology resolved without intervention. The patient further reported abdominal discomfort in the epigastric region. He reported anxiety and hand tremors. Clinical Institute Withdrawal Assessment (CIWA) scale was calculated at 6. Imaging in the emergency department (ED) with a computed tomography (CT) scan of the abdomen pelvis showed cirrhotic liver with varices and an inguinal hernia without obstruction. Labs showed hemoglobin of 11.5 and potassium low at 2.9. The LFTs (liver function tests) were remarkably normal. The alcohol level was elevated to 203.

The inpatient hospital admission was medically necessary.
Based on the provided documentation, the patient is having signs of alcohol withdrawal, along with hematemesis. This complex presentation requires close attention and advanced therapies, which cannot be delivered under observation care. Alcohol withdrawal, vomiting, severe electrolyte derangements, and a CIWA score of 6 while still actively intoxicated, as evidenced by an elevated alcohol level, are qualifying diagnoses for inpatient admission. Furthermore, the patient experienced at least a 1 g (gram) decrease in hemoglobin compared to admission, with severe iron deficiency in laboratory studies. The underlying cirrhosis increases the risk of gastrointestinal bleeding due to synthetic liver dysfunction and esophageal varices presence. Typical treatment involves administering intravenous proton pump inhibitor (PPI), octreotide drip, IV antibiotics, serial H&amp;H's (hemoglobin/hematocrit), and closely monitoring hemodynamic status. Based on the presentation, the anticipated length of stay is more than 48 hours, which exceeds observation and requires an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pectus Carinatum
Treatment: durable medical equipment: spinal orthosis
The insurer denied durable medical equipment: spinal orthosis.
The determination is upheld.

This is a patient with a past medical history (PMH) significant for pectus carinatum. He was previously evaluated by a pediatric surgeon and attempted bracing therapy but patient had concerns about it fitting well. Per the pediatric surgeon's note, the patient notes having occasional chest pain that might be related to injury after working out. The patient is interested in restarting pectus bracing therapy. The patient is seeking approval due to a concern that bracing therapy is necessary due to symptoms and that treatment is not for cosmetic reasons. The surgeon notes no shortness of breath or exercise intolerance. At issue is the medical necessity of durable medical equipment: spinal orthosis.

The spinal orthosis/ pectus carinatum bracing is not medically necessary in this patient's case. Based on medical documentation, he has no shortness of breath or exercise intolerance. Occasional chest pain was not felt by the surgeon to be due to pectus carinatum. The surgeon notes in their assessment that the "carinatum deformity is unlikely to cause any significant physiological problems." Based on the literature, pectus bracing is effective in patients with a compliant and non-stiff chest. This patient has a reported stiff chest wall per the surgeon.  Pectus bracing for pectus carinatum has not been shown to be effective in this setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis.

Treatment: Hospital admission.

The insurer denied coverage for hospital admission.

The denial is overturned.

The patient is an infant who had fever and had been coughing with nasal congestion for two days. The patient's parent noted that the child was not feeding well at the breast and had a decrease in urine output. In addition, the parent noted that the child was vomiting and appeared fatigued and decided to take the infant to the emergency department (ED) for evaluation.

In the ED the child was noted to have a fever and was noted to be in respiratory distress with coughing and an elevated respiratory rate. The oxygen saturation was 91-92% on room air. On physical examination the child was noted to have a rapid respiratory rate with bilateral scattered crackles and a bulging right tympanic membrane. The white blood count was elevated at 16.4, bicarbonate (HCO3) was low at 19 and hemoglobin and hematocrit were low at 8.1 and 28.4. A chest x-ray was significant for perihilar hazy opacities with areas of atelectasis and a possible pneumonia. A respiratory viral panel was positive for Respiratory Syncytial Virus (RSV). The child was treated with albuterol nebulizer treatments, an intravenous (IV) bolus of normal saline and IV antibiotics. When the hypoxemia did not improve, IV solumedrol was also administered in the ED. Based on the persistent vomiting, respiratory distress, hypoxemia on room air, need for oxygen supplementation and abnormal blood test results the decision was made to admit the child to the hospital for ongoing treatment with a diagnosis of bronchiolitis, hypoxemia, and a right otitis media.

The infant was treated appropriately in the ED for coughing, hypoxemia and increased work of breathing. The increased work of breathing and hypoxemia did not improve with treatment with bronchodilators, IV fluid bolus, antibiotics and dexamethasone. The decision to admit the child with a diagnosis of bronchiolitis, right otitis media and possible pneumonia for continued treatment with oxygen supplementation, IV antibiotics, IV fluids and albuterol was medically indicated, and the child could not have been safely discharged to home.

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: Analgesia, anxiolysis, inhalation of nitrous oxide
The health plan denied the analgesia, anxiolysis, inhalation of nitrous oxide
The determination is overturned.

The patient is a female who had impacted wisdom teeth #1, #16 and #32 removed with nitrous oxide sedation. At issue is the medical necessity of analgesia, anxiolysis, inhalation of nitrous oxide.

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

The requested health service/treatment of analgesia, anxiolysis, inhalation of nitrous oxide is medically necessary for this patient. The decision to use sedation for a particular dental procedure should only be determined by considering the needs of the patient, the requirements of the operating dentist, and the effect on the quality of the dental treatment. The provider has determined that it is needed in this particular case due to the nature of the procedure and the patient's anxiety. This is an invasive procedure which would require sedation in the majority of patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Admission
The insurer denied the inpatient admission. 
The health plan's determination is upheld.
 
The patient is a female with a history of gastritis who presented to the emergency department (ED) for evaluation of intermittent chest pain and shortness of breath for the past 10 days. Her symptoms were associated with nausea and left arm tingling. In the ED, the patient's vital signs (VS) were stable. Her laboratory studies were notable for hyponatremia (128) and hypokalemia (3.4). The chest x-ray (CXR) was clear. The electrocardiogram (ECG) showed normal sinus rhythm without ischemic changes. Her high sensitivity (HS) cardiac troponins were negative. She was admitted to telemetry service under inpatient level of care for evaluation of chest pain. She was administered intravenous fluids (IVF) and treated with Proton-pump inhibitors (PPI) twice a day (BID), Tylenol and Lidocaine patch. The patient was discharged home the same day after she was ruled out for acute coronary syndrome (ACS).

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The inpatient level of care was not medically necessary for evaluation of this patient's chest pain. The patient presented with atypical chest pain symptoms, had no cardiovascular (CV) risk factors for coronary artery disease (CAD), her ECG (electrocardiogram) was normal, and HS (high sensitivity) cardiac troponins were negative. The patient's calculated History, electrocardiogram (EKG), Age, Risk Factors and Troponin (HEART) score (1) was low risk not warranting inpatient level of care. Rather, according to the well-validated HEART pathway and the 2022 American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department, an alternate level of care for evaluation of chest pain in this case would have been appropriate and safe for this patient (1-3).

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is overturned.

The patient is a male with a history of chronic low back pain. He was treated with physical therapy, epidural injections, muscle relaxers and anti-inflammatories. Magnetic resonance imaging (MRI) of the lumbar spine revealed disc degeneration.

The proposed Intraosseous Basivertebral Nerve Ablation Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Intraosseous Basivertebral Nerve Ablation Procedure (Intracept) is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. A review of available up-to-date publications utilizing BVN (Basivertebral) ablation in the treatment of vertebral pain suggests that there is quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to evidence that BVN radiofrequency ablation (RFA) is superior to conservative care for pain reduction, at least at 3-month follow-up. Also, there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious AEs (adverse events) based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a male patient diagnosed with Vertebrogenic Low Back Pain. The records provided note that the patient was recommended to undergo the Intraosseous Basivertebral Nerve Ablation Procedure (Intracept procedure), which was denied by the health plan.
It was noted that the patient has a history of low back pain that began over 6 months ago. The patient has tried multiple treatments including medication management, physical therapy, and epidural steroid injections. Medications have included Advil and Tizanidine. Pain is impacting activities of daily living and nothing has provided significant sustained relief. 

Intraosseous Basivertebral Nerve Ablation 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 is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, the MRI report also shows moderate L (lumbar) 4 - L5 central spinal stenosis and moderate bilateral L5 - S (sacral) 1 foraminal stenosis, which are likely pain generators.

This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure. Therefore, there is no evidence that this treatment is likely to be more beneficial than standard treatments for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a male who has low back pain. He had bilateral L (lumbar) 4/5 Transforaminal epidural injections with near complete resolution of low back pain for 2 weeks. His back pain is worse at night and in the morning. His pain level is 5/10. Physical exam (PE): decreased lumbar spine range of motion (ROM), paraspinal tenderness, pain with flexion and extension and positive facet loading test. An magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease with facet arthropathy at L4/5 and L5/S (sacral)1 levels, and moderate bilateral L5/S1 foraminal stenosis. The provider recommended L4/5 epidural steroid injection, and L4-5 L5-S1 BVN (basivertebral nerve) ablations.

Intraosseous Basivertebral Nerve Ablation 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 Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient responded to the prior lumbar transforaminal epidural steroid injections and his PE showed positive facet loading test. MRI revealed multilevel degenerative disc disease with facet arthropathy at L4/5 and L5/S1 levels, and moderate bilateral L5/S1 foraminal stenosis, but no Modic changes. Modic changes on MRI is the most important diagnostic criteria for vertebrogenic pain. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the primary inclusion criteria is Type 1 or Type 2 Modic changes on an MRI at one or more vertebral bodies from L3 through S1. In addition, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were in the exclusion criteria.
Given this patient's clinical presentation, MRI findings of facet arthropathy without Modic changes, and the current clinical evidence, the Intracept Procedure is not likely to be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Neurodermatitis.
Treatment: Dupixent Syringe 300.
The insurer denied: Dupixent Syringe 300.
The denial is upheld.

The patient is an adult male with atopic neurodermatitis/prurigo nodularis, 5-8% BSA (body surface area). He has been treated with topical steroids, phototherapy, and antihistamines. His provider is requesting Dupixent. The patient also has HIV (human immunodeficiency virus). The health plan denied coverage of the request, as they require use of a topical calcineurin inhibitor, phototherapy for at least three months, as well as intralesional corticosteroids. The denial is being appealed.

The health plan should not cover the requested Dupixent.

The health plan's requirement of the use of a topical calcineurin inhibitor, phototherapy for at least 3 months and intralesional corticosteroids is appropriate. These are standard therapies for prurigo nodularis before initiating systemic therapy. Prurigo nodularis (PN) is a chronic dermatoses characterized by intensely pruritic, excoriated, or lichenified nodules. Standard therapy includes corticosteroids, antihistamines, and phototherapy. A trial of consistent phototherapy and
intralesional steroids is within the standard of care. The records of the patient's phototherapy do not include documentation of the phototherapy sessions or how long this was continued. Two to three months minimum is generally required. Intralesional steroids can be an alternative to topicals and are generally a more effective method of delivery of steroid to the skin. The submitted records included an expert panel consensus on Prurigo nodularis. This was published in 2021, prior to approval of Dupixent for Prurigo nodularis. This article states that all treatments are currently used off-label, and there is high variability in treatment selection and lack of consensus on dosing regimens. Treatment goals are to reduce pruritus, interrupt the itch-scratch cycle, and completely heal PN (Prurigo nodularis) lesions. Adequate treatment of PN (Prurigo nodularis) must address both the neural and immunologic components of pruritus. Current PN treatments include gentle skin care,
antipruritic emollients, topical corticosteroids, topical calcineurin inhibitors, topical capsaicin, neuromodulators (e.g., gabapentinoids, cannabinoids, or anesthetics), antidepressants, phototherapy, and immunosuppressants. This article suggests a
"tier" system for treatments, utilizing topicals and intralesionals followed by phototherapy, and considering systemic therapy if these failed.