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

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is: Upheld

The patient is a female with a history of low back pain. The pain began 2-3 years ago. Prior treatments have included back surgery, injections, as well as epidural injections. Prior treatments have included tramadol. The pain impacts activities of daily living (ADLs). Pain score ranges from 6-8 out of 10. Magnetic resonance imaging (MRI) demonstrated Modic changes lumbar (L)4-5. The subject under review is the proposed Intracept procedure.

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: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is: Overturn

This is a female with a medical history of diabetes mellitus (DM), peripheral vascular disease (PVD), depression, hypertension (HTN), coronary artery bypass graft (CABG) and lumbar (L) 4/5 decompression. She has primarily chronic axial low back pain with pain in the right lateral thigh. She previously underwent epidural steroid injections with only temporary pain relief. Her pain is aggravated by physical activities. She was evaluated by a spine surgeon who recommended Intracept procedure for pain management, and lumbar fusion as the last resort. Physical exam (PE) of lumbar spine was unremarkable. Magnetic resonance imaging (MRI) revealed multilevel degenerative changes with foraminal stenosis and endplate degeneration in L4/5.
The issue is whether Intracept procedure is likely to be more beneficial for this patient than any standard treatment.

The proposed Intracept procedure is likely to be more beneficial for this patient. The intraosseous nerve ablation procedure (Intracept) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. Her lumbar spine MRI revealed endplate degeneration in L4/5, which is a diagnostic criteria for vertebrogenic pain. She had tried conservative treatment including an epidural injection without adequate relief. Further interventions are medically necessary to improve her pain. Further surgical option of lumbar fusion was discussed. However, the spine surgeon recommended fusion as the last resort, and recommended Intracept for pain management. Given this clinical scenario, Intracept procedure is the most appropriate next step intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Irregular Heart Rhythm
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult female patient was hospitalized. The patient had presented to the emergency department for evaluation of palpitations, in the setting of her past medical history (PMH) pertinent for cerebral vascular accident (CVA) earlier that month and treated with anti-hypertensives, statin and aspirin therapies. The patient was to get a Holter monitor study by her cardiologist. 
However, Emergency Medical Services (EMS) found the patient to be in new atrial fibrillation with rapid ventricular response (RVR). Treatment included intravenous metoprolol followed by oral intake. The patient's vitals were stable. There were no new neurologic deficits. Rhythm spontaneously reverted to sinus and the patient was discharged to home the next day. The request for coverage for inpatient hospitalization has been denied by her Policy and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer reviewed medical literature, the documentation submitted for review does not establish that the requested acute inpatient hospital stay was medically necessary for this patient. 
The Milliman Care Guidelines (MCG) guideline for Atrial Fibrillation (ORG: M-505) criteria for inpatient admission are not met, including hemodynamic instability, myocardial ischemia, syncope, altered mental status, dyspnea or hypoxemia, pulmonary edema, continuous cardiac monitoring is required for condition causing arrhythmia, such as, serious electrolyte abnormality, any underlying medical condition requiring inpatient care like thyrotoxicosis or pneumonia, recent systemic embolic event like cerebral vascular accident (CVA), initiation of antiarrhythmic drug (AAD) therapy for patient at high risk for adverse effects like use of antiarrhythmic drug with proarrhythmic potential, low ejection fraction, congenital heart disease, valvular heart disease, prolonged QT interval, significant sinus or atrioventricular (AV) node conduction disease, intolerable symptoms despite optimal outpatient treatment or elective or urgent cardioversion which cannot be done on an outpatient basis or during observation care. In this particular case, the care the patient received, including medication for ventricular rate control in a hemodynamically stable patient, is routinely provided safely and effectively at a lower level of care, such as at the Observation level of care. Therefore, based on the submitted information and the standard of care, the proposed treatment, inpatient level of care is not medically necessary for this member.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis 
Treatment: Inpatient hospital services
The insurer denied coverage for inpatient hospital services
The denial is upheld

Per clinical documentation, this patient presented to the Emergency Department (ED) with right upper quadrant abdominal pain. There was associated nausea without vomiting. Vital signs in the ED were significant for a blood pressure of 165/86 and a pulse rate of 113. White blood cell count was normal at 9.4. Liver function tests were within normal limits. An abdominal ultrasound demonstrated acute cholecystitis. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged the following day. 

Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per Milliman Care Guidelines (MCG) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. [7] According to clinical documentation, the patient did not meet criteria for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be observation status. Inpatient admission is not medically necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Restless leg syndrome

Treatment: Gralise 600 milligrams (mg) OR (oral) tabs (tablets)

The insurer denied coverage for Gralise 600 milligrams (mg) OR tabs

The denial is upheld. 

This case involves an adult diagnosed with insomnia, chronic restless leg syndrome, systemic lupus erythematosus related syndrome, hyperlipidemia, and gastroesophageal reflux disease. The patient received a notice of adverse determination regarding Gralise. It was determined that the proposed use of the drug did not meet requirements set forth by the managed care plan. Records stated that the patient had taken Gralise for almost ten years given her diagnosis of restless leg syndrome. She previously tried and failed gabapentin as it was ineffective. The physician stated that switching the patient's medication would be medically inappropriate at this time. Progress notes stated the patient was taking 1800 mg of Gralise each night. Prior testing indicated the periodic limb movement index was 41.6 with most associated with electrographic arousal, frequent leg movements while awake, and drowsiness consistent with restless leg syndrome. The patient stated that in addition to Gralise, she was taking magnesium for the restless leg syndrome. The impression at that time included the persistent insomnia with restless leg syndrome and reports of incomplete control of the insomnia with current medications.  She reported nocturnal awakenings with changing of positions multiple times at night. This review pertains to Gralise 600 mg oral tablets.

The Food and Drug Administration states that Gralise (gabapentin) is indicated for the management of postherpetic neuralgia. Current peer-reviewed literature states that the top five indications for gabapentin were for neuropathic pain, musculoskeletal pain, restless legs syndrome, anxiety, and headache. The information provided for the review stated that the patient was taking 1800 mg of Gralise each night to treat restless leg syndrome. The information provided for the review did not suggest that the medication was substantially beneficial in reducing the patient's symptoms given that she was also taking magnesium to treat the condition and reported nocturnal awakenings multiple times at night.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Gralise 600 milligrams (mg) OR tabs is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who initially presented to the emergency department with concerns of chest pain. Pertinent history included coronary artery disease with a history of coronary artery bypass graft (CABG), hepatitis C, diabetes mellitus, and hypertension. 

Based on the clinical documentation provided, evidence based literature and standards of care, the inpatient hospital admission was not medically necessary. The patient had a history of coronary artery disease and presented with chest pain. The initial evaluation found the patient to be hemodynamically stable and without hypoxia. Initial diagnostic testing revealed a deep vein thrombosis and bilateral pulmonary emboli. An echocardiogram did not reveal cardiac strain. Intravenous morphine was given to assist with pain control in the emergency department. Following observation care, anticoagulation was successfully transitioned to apixaban. No hemodynamic instability, hypoxia, or bleeding events were documented throughout. No other issues or complications were documented throughout.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Vascular Accident. 
Treatment: Functional Neuromuscular Stimulator. 

The insurer denied a Functional Neuromuscular Stimulator. 

The health plan's determination is overturned. 

This is a female patient with left basal ganglia hemorrhagic stroke with spastic right hemiparesis. Under review is the medical necessity for a functional neuromuscular stimulator. 

The functional neuromuscular stimulator is medically necessary for this patient. It will help to reduce spasticity and increase range of motion in this patient. The stimulator can reduce atrophy, osteoporosis, and improve blood flow to the limb as well. Also, in some cases, there is improvement in muscle strength due to muscle re-education with use of the device. Therefore, it is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

This is an adult male with type-one diabetes who presented to the Emergency Department with six days of vomiting and decreased oral intake. He had stopped his insulin five days prior. 

The patient's temperature was 37 degrees Celsius, heart rate was 71, blood pressure was 132/81, oxygen saturation (O2) was 99%(percent). The patient's glucose was 469, sodium 128, chloride 88, carbon dioxide (Co2) 17.8, anion gap 22, hematocrit 52.6, total bilirubin 2.0, and beta-hydroxybutyrate greater than (>) 4.5. The patient was treated with intravenous fluids, regular insulin push, acetaminophen, and ondansetron. The patient required additional ondansetron and metoclopramide for ongoing vomiting. He was treated with insulin drip and transitioned overnight with normalization of his serum bicarbonate. A computed tomography (CT) of the abdomen/pelvis was ordered due to ongoing nausea and vomiting and showed mild colitis. He was treated with intravenous ciprofloxacin and metronidazole. He was made nothing by mouth (NPO) and treated with dextrose infusion. On the second day, he was noted to have no further 
vomiting but with some nausea. No abdominal pain was noted since the evening before. He was started on clears and diet was advanced as tolerated. Inpatient stay is under review. 

The proposed inpatient stay was medically necessary. 

The proposed inpatient stay was medically necessary. This patient presented with diabetic ketoacidosis with nausea and vomiting. His glucose and acidosis responded to intravenous fluids and insulin, but he had ongoing nausea and vomiting. He 
underwent computed tomography of the abdomen and pelvis which demonstrated colitis. He was made nothing by mouth (NPO) due to ongoing nausea, vomiting, and abdominal pain. He was started on clear diet on the second day and was discharged the following day. Therefore, the patient did require an inpatient stay due to persistent nausea and vomiting in the setting of diabetic ketoacidosis and colitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease, hypertension, hyperlipidemia, and obesity

Treatment: Personal Care Aide (PCA) services, 84 hours per week

The insurer denied coverage for PCA services, 84 hours per week

The denial is overturned

The patient is an elderly adult with Alzheimer's disease and progressive dementia.  The patient is currently approved PCA 5 hours/day, 7 days/week: totaling 35 hours/week.  The request is for PCA 12 hours/day, 7 days/week for a total of 84 hours/week. 

In the Uniform Assessment System (UAS) report, the patient's cognition is described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times."  The patient requires extensive assistance for bathing, personal hygiene, dressing and toilet use.  The patient is occasionally incontinent of bladder and continent of bowel.  Limited assistance is needed for toilet transfers and ambulation.  The patient is independent for bed mobility and supervision for eating.  Cognitive status has declined.  There has also been a significant decline in functional ability particularly for bathing, dressing, and personal hygiene.  The combination of the patient's declining cognitive status and functional ability support the medical necessity of increasing PCA to 12 hours/day, 7 days/week, totaling 84 hours/week.  In addition, the patient's condition and functional needs are at a level, unpredictable and declining, as to require the requested PCA 84 hours/week.  

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 personal care aide (PCA) services, 84 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is upheld

This patient was washing dishes and began to feel lightheaded and sweaty. The patient fell to the floor and remembered feeling pain along the right foot as he lost consciousness and hit his head.  Past medical history was significant for hypertension. Upon arrival to the hospital, vital signs were stable (blood pressure (BP) 99/66mmHg (millimeters of mercury), pulse 66bpm [beats per minute]). Physical exam was significant for a broken second right toe and swelling along the left parietal portion of the head. The patient was not orthostatic.  A 12-lead electrocardiogram revealed normal sinus rhythm with left ventricular hypertrophy. Serum blood testing revealed no significant abnormalities.  Computed tomography (CT) of the head demonstrated no intracranial pathology. The patient was admitted to the hospital for evaluation and treatment. Echocardiogram demonstrated normal wall motion and a left ventricular ejection fraction of 54% (percent). Following a period of observation, the patient was discharged. 

According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality (Reference 1). In a study of individuals presenting to the emergency room, patients that were low risk for cardiac events (no significant cardiac history or acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2).  In this case, the patient falls into a low-risk category and could be managed a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visit services
The insurer denied coverage for D8080 braces and D8670 monthly visit services
The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, a montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified an anterior crossbite. The orthodontist has completed the Handicapping Labio-lingual Deviation Index (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 13 points by internal reviewers when 26 points are required for approval. 

Upon review of the submitted documentation it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD New York State Medicaid program) modeled after Handicapping Labio-lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic 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 D8080 braces and D8670 monthly visit services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient had a history of gastritis and chronic cannabinoid use and presented with abdominal pain, nausea, and vomiting. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal and pelvic computed tomography (CT) scan showed mild cystitis. He was diagnosed with cyclic vomiting due to marijuana use. Intravenous (IV) hydration, antiemetics, metoclopramide, and famotidine were given. He denied having any urinary tract symptoms. He responded well to the treatment that was given and his symptoms improved. 

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Care Guidelines (MCG) M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

Clinical indications for admission for Vomiting (MCG M-370) include having a significant metabolic derangement such as ketoacidosis, hemodynamic instability, severe electrolyte abnormalities, severe pain, bacteremia, acute renal failure stage 3, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had cycling vomiting that was felt to be related to cannabinoid use. He required treatment with IV hydration, antiemetics, and famotidine. However, this treatment could have been given in the emergency room (ER) with observation status. He responded well to the treatment and improved. He did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Vomiting. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for hospital inpatient services substantiated.