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

Diagnosis: Orthopedic/Musculoskeletal/Back pain
Treatment: Surgical Services/Intracept System
The health plan denied the requested Intracept System as experimental/investigational. The health plan's determination is upheld.

This is a patient with low back and right hip pain with a magnetic resonance imaging (MRI) of the lumbar spine showing (lumbar) L3-5 moderate stenosis in the neuroforamina. Under review for medical necessity is a request for a basivertebral ablation.
At issue is whether the proposed health service or treatment of an Intracept System 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 an Intracept System is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease, as there are no large long-term studies that have shown clear safety and efficacy of this procedure. In the patient cohort such as this, given the moderate foraminal stenosis noted on the MRI of the spine, this procedure can contribute to causing ongoing back and leg pain, including hip pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back pain
Treatment: Surgical Services/Intracept System
The health plan denied the requested Intracept System as experimental/investigational. The health plan's determination is upheld.

This is a female with a history of low back pain. She has had physical therapy and medications without relief. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows degenerative changes (lumbar-sacral) L4-S1. The provider has recommended an Intracept procedure for (lumbar) L3-5.
At issue is whether the proposed health service or treatment of an Intracept System 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 Intracept System in not more likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
While this is a promising technology, the literature describes further research needing to be performed, particularly from non-industry sources. Urits et al cite "CLBP (chronic low back pain) is a difficult yet common diagnosis that affects a significant portion of patients worldwide. In efforts to combat this debilitating disease, researchers have made great progress in understanding the pathophysiology of lower back pain (LBP) in addition to unveiling the anatomy of the vertebrae in search of appropriate treatment options. As a result, with the growing evidence supporting the vertebrogenic model that involves the basivvertebral nerve (BVN), radiofrequency (RF) ablation of the BVN has emerged as a possible minimally invasive procedure to treat LBP. Several studies have supported the safety, durability, and efficacy of RF ablation of the BVN. There is also convincing evidence that BVN ablation is more beneficial than the current standard of care for the treatment of CLBP. However, reproducible large random clinical trials (RCT) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future."
Appeal type: Medical necessity
Decision: Upheld

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

This patient presented to the Emergency Department (ED) with abdominal pain. The patient had a history of Helicobacter pylori (H. Pylori) that was found on a previous endoscopy. The patient had a cholecystectomy and Endoscopic retrograde cholangiopancreatography (ERCP). The patient was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A Computed Tomography (CT) scan revealed a focal ileus and intraductal biliary air. A Magnetic resonance cholangiopancreatography (MRCP) was negative for acute disease. The pneumobilia was felt to be related to the previous ERCP. The patient was given a Proton-pump inhibitor (PPI) therapy and 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, and bacteremia. The patient did not meet this criteria and did not have these conditions. 

This patient had abdominal pain and responded to PPI therapy. Intravenous (IV) hydration, antiemetics, and PPI therapy could have been given in the ED with observation care. The MRCP could have been done as an outpatient. There was no evidence of acute liver or biliary tract disease at this time. The patient did not meet MCG criteria for Undiagnosed Abdominal Pain. 

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Problem/Loss
Treatment: Cochlear Implants
The health plan denied: Cochlear Implants
The determination is: Overturned

The patient is a female with hearing loss. She receives little benefit from hearing aids. Her AzBio testing is less than 10 percent (%). Her Consonant-vowel Nucleus Consonant (CNC) testing is less than 30%. Her audiogram shows moderate to severe bilateral hearing loss. Her provider has recommended cochlear implants.
At issue is the medical necessity of cochlear implants.
The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service/treatment of cochlear implants is medically necessary for this patient.
The patient has moderate to severe bilateral hearing loss. She has no significant benefit with hearing aids as noticed by AzBio testing. There are no reasonable alternatives for this patient to hear.
The patient meets generally accepted guidelines for cochlear implantation as practiced in the United States. Well-designed studies have shown that this patient will experience significant hearing benefit with this procedure. The request is consistent with current FDA (Food and Drug Administration).  The request is consistent with the current standard of care. The request is not experimental or investigational.
Without this surgery she has no serviceable hearing. Therefore, the cochlear implants are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: brachymetatarsia of the left foot
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
The medical records did not show a condition to require the level of service provided (i.e. Full admission). The current diagnosis for treatment was infection to pin sites of external fixator. The young girl had undergone treatment for "brachymetatarsia" to the 4th metatarsal. Simply stated she has a short 4th metatarsal, and a lengthening procedure was performed. Pin tract infection is common and usually treated with home care and oral antibiotics. She had ongoing problems thus additional care was provided. 

Her surgical procedure was 14 (fourteen) minutes with blood loss of 1cc (cubic centimeter). Her physician elevated the fixator bar and debrided the pin sites. Her post-surgical course was non complicated. She did not have a fever. There was no bleeding. She was able to tolerate oral medications. She was able to ambulate. She did not require additional treatment nor imaging for underlying medical conditions. There were no extenuating circumstances to substantiate the level of care provided. 

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: back pain.
Treatment: spinal cord stimulator.
The insurer denied a spinal cord stimulator. 
The health plan's determination is overturned. 

This is a female with a long-standing history of back and leg pain. Her pain is severe and limits her ability to function. She had tried and failed conservative treatments including a lumbar epidural injection. She was evaluated by a neurosurgeon who recommended spinal cord stimulation. 

A Spinal Cord stimulator is medically for this patient.
This patient has severe back and leg pain with functional limitations from lumbar degenerative disc disease (DDD) and radiculitis. Further treatments are medically necessary to improve her pain and function. Her neurosurgical evaluation indicated she is not an appropriate surgical candidate and spinal cord stimulation is the next step intervention. Current clinical studies support spinal cord stimulation is an effective intervention for back and leg pain. Given this clinical scenario, spinal cord stimulation is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type I diabetes mellitus
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission.
The denial is upheld. 

The patient is an adult female, with a medical diagnosis of type I diabetes mellitus. She presented to the emergency department (ED) complaining of polyuria, polydipsia, fatigue, generalized malaise and nausea associated with hyperglycemia with blood glucose levels elevated to 200-400 milligrams per deciliter (mg/dL) for the previous three days. The patient reported to have run out of her long-acting insulin, Tresiba, four days prior and have been unable to fill it due to problems with her insurance coverage. As a result, she was forced to only use her short acting insulin Admelog.

Upon arrival, the patient was hypertensive with an elevated blood pressure of 146/100 millimeters of mercury (mmHg) and tachycardia, with a heart rate of 113 beats per minute. The patient's blood work indicated an elevated fasting sugar of 408 mg/dL (milligrams per deciliter), an elevated blood glucose of 387, decreased phosphorus of 2.2, and an elevated A1C of 10.5% (percent).

The patient was initially treated with a one-liter bolus of lactated ringers, potassium, subcutaneous Lantus 38 units, and subcutaneous Admelog three (3) units.

The patient was admitted with a diagnosis of hyperglycemia. The inpatient plan of care included serial blood work, tight glycemic control, continuation on Lantus 38 units at bedtime, Admelog five (5) units three times daily prior to meals with low dose insulin sliding scale, and an endocrinology consult. The patient was evaluated by endocrinology, and she was to be discharged on the long-acting insulin Basaglar 48 units at bedtime, as it was newly covered by her insurance.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and shortness of breath. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is an adult woman with a past medical history of hypertension, diabetes mellitus type II, hyperlipidemia, Hodgkin's lymphoma, remote tobacco abuse, marijuana use, anxiety, and coronary artery disease with a recent non-segment (ST) elevation myocardial infarction (NSTEMI) requiring percutaneous coronary intervention (PCI) of the left main coronary, and an associated cardiomyopathy with left ventricular ejection fraction (EF) of 30-35% on a recent echocardiogram. She presented to the emergency department (ED) of South Nassau Communities Hospital with chest pain and shortness of breath.

Cardiology noted that the patient had been seen in the emergency department (ED) 2 days previously with similar symptoms and had been subsequently seen by her cardiologist, and that the patient has had right-sided chest pain since chemotherapy was started. Tingling/numbness in the fingers and lower extremities was noted, and a cramping sensation in her left calf, and 48 hours of bilateral shoulder pain. Respiratory distress and tachypnea were noted. An electrocardiogram (EKG) was unchanged from prior EKG. Other than serial enzymes and usual care, there were no acute cardiology recommendations, with a working diagnosis of atypical chest pain. Neurology workup, to potentially include magnetic resonance imaging (MRI) and neurology consult, was considered. Her symptoms were noted as "tingling/numbness to fingers and hip to feet along with calf pain described as cramping sensation." 

The patient's symptoms had largely been stable since her recent percutaneous coronary intervention (PCI). Routine care was planned, including telemetry admission, serial enzymes, and basic labs (ionized calcium, parathyroid hormone) to evaluate the mild hypercalcemia. 

Initial troponin was normal at 0.029. Carbon dioxide (CO2) was low at 17.6 (normal: 22-30 mmol/L). Calcium was slightly high at 10.8 (normal: 8.5 - 10.5 mg/dL). Anion gap was elevated at 20 (normal: 7-16 mmol/L). A head computed tomography (CT) was reassuring. A computed tomography angiogram (CTA) of the pulmonary arteries was negative for pulmonary embolism (PE). A chest X-ray was reassuring. Cardiology had recommended serial enzymes. Rule out myocardial infarction (MI), rule out pulmonary embolism (PE), and metabolic acidosis were noted in the admission decision. Neurology noted no abnormal findings other than mild carotid disease. 

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 the inpatient admission Hospital is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pharyngitis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

According to the medical records, the patient is an infant who presented with dehydration and fevers. He presented to the emergency room (ER) with complaints of a three (3) day history of drooling and fever. Imaging revealed soft tissue result with diffuse enlargement of the tonsillar tissue of Waldeyer's ring with mild airway effacement. The patient was medicated as ordered. Otolaryngology was consulted over the case. Antibiotics were recommended for likely pharyngitis. There were no acute events overnight. His drooling and oral intake improved. The patient was discharged. The request is to determine if the admission was considered medically necessary. 

The infant presented with a fever and decreased oral intake, necessitating hydration and antibiotic administration. The overnight admission allowed for further management and a means to avoid any airway compromise. This is appropriate given the need for aggressive management of a patient that young. 

The assessment of the severity of dehydration is essential, as therapy instituted should be based on its severity" (Kight, B. P., & Waseem, M. 2022). 

"Assessment of body fluid status is an integral component of the physician's evaluation of most hospitalized patients. A competent fluid assessment requires sound knowledge of the dynamic interaction between body fluid compartments, as well as a skillful examination and careful biochemical analysis of serum and urine. In addition, a command of medical language and terminology is essential to precisely describe and categorize body-fluid status" (Asim, M., et al. 2019). 

"Pharyngitis is the inflammation of the mucous membranes of the oropharynx. In most cases, it is caused by an infection, either bacterial or viral. Other less common causes of pharyngitis include allergies, trauma, cancer, reflux, and certain toxins" (Wolford, R. W., et al. 2022). 

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, hypertension
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

The patient is an adult female. She was admitted for worsening abdominal pain. The patient's labs were notable for hypomagnesemia. Urine Toxicology was positive for Cocaine. 
She was treated with intravenous Magnesium during that time. A CT (computed tomography) Head without contrast was performed, which was negative for acute intracranial process. She was also treated with antihypertensive medication for elevated blood pressure. She was discharged in stable condition on day #3.

The Inpatient Hospital Admission was not medically necessary.

The patient was admitted for elevated blood pressure with abdominal pain, and her condition resolved in 48 hours. Her condition could have been treated safely under lower level of care per evidence-based literature. An evidence-based specialty society guideline concludes that adult patients with severe hypertension (e.g., SBP [systolic blood pressure] greater than 180 mmHg [millimeters of mercury] or DBP [diastolic blood pressure] greater than 120 mmHg [millimeters of mercury]) without acute or worsening target organ damage (sometimes deemed a hypertensive urgency) can be treated with oral medication, and do not require inpatient care [1]. Database analysis of a cohort of 552,569 patients (mean age 58 years) discharged from an emergency department with a primary diagnosis of hypertension found that in the weeks after 
discharge the rate of intracerebral hemorrhage was exceedingly low (less than 0.02%), and not elevated to a statistically significant degree compared to the rate the same patients experienced over the same time period a year later [2]. In the same analysis, among the 10,288 patients discharged with a diagnosis of malignant hypertension, the rate was similarly low (0.03%), and also not different from the same time period a year later. A multiyear database analysis of patients seen in a Canadian emergency department with a primary diagnosis of hypertension found in the last year of the study (25,950 patients, median age 64 years) that over 92% of patients were treated without admission to inpatient care [3].
Therefore, given the above, Inpatient Hospital Admission was not 
medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fractured tibia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

The patient is an adult male. The patient had a hospital admission at an inpatient level of care. The patient sustained a closed fracture of the distal end of the left tibia and had treatment with insertion of an intramedullary nail of the left tibia. The patient was presented to the emergency department after an altercation and sustained a left leg injury. The patient was intoxicated at the time of admission. The x-ray revealed a tibial shaft fracture. The patient had an orthopedic consultation and underwent intramedullary nailing of the left tibia. The patient had treatment with postoperative occupational and physical therapy and then was discharged to home the following day with outpatient therapy. This is a review for the inpatient level of care.

The Inpatient Hospital Admission was not medically necessary.

The patient had a single injury to the left tibia that required surgical intervention. The patient had routine postoperative treatment including analgesics and physical therapy. The need for the inpatient admission has not been established. The patient had an extensive workup in the emergency department, which revealed only the single injury. There were no complications or other diagnoses that required treatment during the hospital admission. Thus, the inpatient level of care was not appropriate, since the patient could have received the same services at a lower level of hospital care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe obstructive sleep apnea. 
Treatment: Durable Medical Equipment - E0562 - heated humidifier with Positive Airway Pressure device (PAP) 7 units and E0601 - PAP device 7 units. 
The insurer denied coverage for Durable Medical Equipment - E0562 - heated humidifier with Positive Airway Pressure device (PAP) 7 units and E0601 - PAP device 7 units. 
The denial is upheld. 

There is no document that explains the requirement of the Positive Airway Pressure (PAP) and supplies. If this is for sleep apnea, a progress note with compliance data is needed. Also needed is documentation of the current pressure settings, any residual Apnea Hypopnea Index (AHI), any insomnia as comorbidity, any need for pressure or mask change etc. We also need to know whether there are any changes in Body Mass Index (BMI) or any diagnoses that can cause central apnea. We also need information as to how new or old the requested Durable Medical Equipment (DME) is and any malfunction. Without this documentation the medical necessity of the requested Durable Medical Equipment (DME) cannot be determined. 

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 Durable Medical Equipment - E0562 - heated humidifier with Positive Airway Pressure device (PAP) 7 units and E0601 - PAP device 7 units services is not substantiated.