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

Diagnosis: occipital nerve pain

Treatment: pain injections (64405 x 1)

The insurer denied coverage for pain injections (64405 x 1)

The denial is overturned


This is an adult female with a diagnosis of occipital neuralgia, cervicalgia, and cervicogenic headaches.

The patient reported that she is experiencing continued pain and symptoms of occipital neuralgia. The patient stated that she had over 90% pain relief for approximately 60 days from her previous occipital nerve block. The patient also endorsed worsening temporomandibular joint (TMJ) pain and migraines that increased her occipital nerve pain. The patient has had more than 6 months of physical therapy since the previous year to address cervicalgia and occipital nerve blocks with minimal therapeutic benefit. The patient has tried at least 3 months of rest and changes in activities to avoid pain triggers. The patient has trialed anticonvulsants (Topiramate, Gabapentin, and Lyrica), and tricyclic antidepressants (such as amitriptyline and duloxetine which provides minimal to no benefits. 

The provider stated the patient suffers nearly daily attacks of left side occipital ridge shooting pain (from the back side of her head/over left ear). The patient has a history of occipital neuralgia, cervicalgia, and cervicogenic headache. The provider indicates in addition to daily avoidance of pain triggers and rest, the patient has trialed Gabapentin, Tramadol, Methocarbamol, Celebrex, Naproxen, Oxycodone for greater than 90 days without success. The patient has also attended multiple rounds of physical therapy, without adequate relief. The patient reported relief of her pain and tenderness with previous occipital nerve block.

Nerve blocks are the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions. 

Milliman Care Guidelines (MCG) indicate greater occipital and lesser occipital nerves arise from the cervical (C2 and C3) spinal nerves. The greater occipital nerve pierces the semispinalis capitis and trapezius near their attachments to the occipital bone, while the lesser occipital nerve ascends through the sternocleidomastoid toward the occipital bone. Occipital nerve blocks have been used in the treatment of cervicogenic headache, cluster headache, occipital neuralgia, and migraines, among other pain conditions. Using physical landmarks or ultrasound guidance, local anesthetic or steroid is injected near occipital nerve fibers to inhibit the activity of the sensory pathway for acute or prophylactic pain management.

Current evidence-based articles indicate that it has been found that occipital nerve blocks have excellent efficacy in alleviating the symptoms of primary chronic headaches, including occipital neuralgia, cervicogenic headache, cluster headaches, migraine. 

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 pain injections (64405 x 1) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperosmolar Hyperglycemic State

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient has a history of type II diabetes, hypertension, hyperlipidemia, and acute kidney injury (AKI) on chronic kidney disease (CKD). The patient presented to the emergency room (ER) with elevated blood glucose, lethargy, polyuria, polydipsia, decreased exercise tolerance, and bilateral lower extremity edema. The patient had been off their medications for few days. The patient stated that there was 2 weeks of worsening bilateral lower extremity swelling associated with worsening exercise tolerance.

Vital signs on presentation included: blood pressure (BP) 141/96, heart rate (HR) 90, and pain score of 6/10.  Labs included: glucose 756, magnesium 2.8, platelets 147, hemoglobin 13.1, blood urea nitrogen (BUN) 34, creatinine 2.11, sodium 130, chloride 94, estimated glomerular filtration rate (eGFR) 37, alkaline phosphatase 366, pH (potential of hydrogen) 7.41, partial pressure of carbon dioxide (PCO2) 44, partial pressure of oxygen (PO2) 58, bicarbonate (HCO3) 27.9, triglyceride 193, anion gap 12.1, troponin 10, and beta hydroxybutyrate 0.25.  A urinalysis revealed: protein 30 and glucose (more than) > 1,000. Calculated serum osmolality was 314, which is elevated. 

The following day, the patient's labs were: glucose 315, creatinine 1.36, calcium 8.4, platelet 148, pH 7.41, PCO2 40, PO2 68, and HCO3 25.4.  Two days after admission, the patient's labs were: BUN 24, creatinine 1.5, eGFR 56, calcium 8.4, potassium 3.4, and glucose 314. 

The patient was diagnosed with hyperosmolar hyperglycemic state, AKI on CKD, pseudohyponatremia and thrombocytopenia. There was no deep vein thrombosis (DVT).  The physical examination revealed that the patient was diaphoretic with bilateral lower extremity edema.

Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state or other comorbid conditions [1-5]. 

This patient did not have diabetic ketoacidosis (DKA) but did have a hyperosmolar state based on a calculated osmolality of 314. The patient also had an acute kidney injury with a creatinine of 2.11 and a blood urea nitrogen (BUN) of 34. The patient had a beta hydroxybutyrate 0.25.  The patient also had hyponatremia and hypochloremia. The patient required inpatient care for symptomatic hyperglycemia and acute kidney injury.

Based on the above, the insurer's denial must be reversed. 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: Nausea, Vomiting and Pain (in the side)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She was admitted for nausea and flank pain. She was found to have a urinary tract infection on urinalysis and was started on intravenous fluid and antibiotics. She was also treated with anti-emetics and pain medications.
A chest X-ray was negative for infection. An electrocardiogram was negative for acute ischemia or arrhythmia. A computed tomography (CT) of the abdomen and pelvis was negative for acute intra-abdominal process. Her condition improved and she was discharged in stable condition.

The Inpatient admission was not medically necessary.

Per MCG (Milliman Care Guidelines) criteria M-300, Admission is indicated for 1 or more of the following:
Hemodynamic instability.
Altered mental status that is severe or persistent
Persistence or worsening of clinical finding (for example (e.g.), fever, pain, dehydration, vomiting) despite observation care
Pregnancy with suspected pyelonephritis
Kidney transplant recipient with suspected pyelonephritis
Significant uropathy (e.g., obstructive defects, moderate to severe vesicoureteral reflux)
Suspected infection of an indwelling prosthetic device, stent, implant, or graft
Ureteral obstruction (e.g., stone)
Bladder emptying significantly impaired (e.g., bladder outlet obstruction)
Renal or perinephric abscess
Emphysematous pyelonephritis or cystitis
Pyonephrosis
Acute renal failure (stage 3 acute kidney injury)
Acute kidney injury (stage 2)
Need for IV hydration support (e.g., inability to maintain oral hydration) despite observation care
Hemodynamic instability was not documented in this case. The patient was without altered mental status that was severe or persistent. The patient was not pregnant with suspected pyelonephritis. The patient was not a kidney transplant recipient with suspected pyelonephritis. Significant uropathy was not documented. There was no documentation of suspected infection of indwelling prosthetic device, stent, implant or graft. Ureteral obstruction was not documented. Significantly impaired bladder emptying is not documented. Renal perinephric abscess was not documented. Emphysematous pyelonephritis or cystitis was not documented. Pyelonephritis was not documented. Acute renal failure or injury was not documented. The need for IV (intravenous) hydration support despite observation care is not documented. Therefore, given the above, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a history of cocaine use. Presenting complaints were dyspnea in the setting of recent cocaine use and combustion exposure. The physical exam was notable for bilateral wheezing. Lab results were unremarkable. Radiology was notable for a chest x-ray with a right lower lobe infiltrate. The patient's dyspnea improved significantly with nebulizer treatments in the emergency department (ED). The patient was admitted to an inpatient level of care for treatment of reactive airway disease and pneumonia. At issue is the medical necessity of an inpatient stay.
The requested service of inpatient admission was not medically necessary. The patient presented with dyspnea and wheezing in the setting of cocaine use and combustion exposure. He was hypoxic on presentation and experienced symptomatic improvement in the emergency department. He was diagnosed with reactive airway disease and pneumonia (Pneumonia Severity Index Risk Class I pneumonia). A lower level of care would have been appropriate to monitor the patient for clinical decompensation, continue therapies for reactive airway disease and prepare for outpatient transition. An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult female patient who was admitted for right upper quadrant (RUQ) pain. She was afebrile on admission and her vital signs were stable. Her white blood cell (WBC) count was 10.5 and she showed mild liver function test (LFT) elevation. Ultrasound/computed tomography (US/CT) showed gallstone and inflammation around the neck of the gallbladder. She was taken to the operating room for laparoscopic cholecystectomy. She was discharged home without any complications.

The requested health service was not medically necessary.

Inpatient admission was not medically necessary per the attached Milliman Care Guidelines (MCG) criteria and standards of care given the patient had uncomplicated acute cholecystitis. The patient underwent laparoscopic cholecystectomy. She had an uneventful post-operative course and was discharged tolerating her diet and her pain well controlled. There is no documentation that supports complications or needing to stay in the hospital at an inpatient level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea, weakness, abnormal lab test (hypokalemia)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This is an adult female patient with Crohn's disease with colectomy. She presented to the hospital with diarrhea, weakness, lightheadedness, and hypokalemia. The patient was aggressively treated with intravenous (IV) fluid and oral and IV potassium supplementation. The patient was seen by gastroenterology and nephrology services. Potassium stabilized from 1.9 milliequivalents/liter (meq/L) to 3.7 meq/L.

The requested health service was not medically necessary.

Inpatient level of care was not medically necessary. Based on available data, the patient could have safely and effectively been managed at a lower level of care. The requested inpatient level of care was for the convenience of the patient or the practitioner; therefore, the requested inpatient level of care was not medically necessary. The patient could have safely and effectively been managed at a lower level of care.

Based on available documentation, there was no hemodynamic instability or hypertension requiring inpatient treatment. There was also no acute cardiac or peripheral ischemia, persistent cardiac arrhythmias or findings of immediate concern, severe heart failure, respiratory abnormalities, severe airflow or ventilation abnormalities, impending or actual respiratory arrest, or neurologic abnormalities or new-onset severe neurologic findings requiring inpatient care. There was no documentation of acute intra-abdominal process with peritoneal signs, significant uremic complications, or severe electrolyte abnormalities that could not have been treated at a lower level of care. Based on available data, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient and, therefore, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder (malocclusion). 
Treatment: D8080 braces, D8670 monthly visit x 12. 
The insurer denied D8080 braces, D8670 monthly visit x 12. 
The determination is overturned. 

The patient is a female with a Class II Division 1 malocclusion with maxillary and mandibular crowding. She has a 6 millimeter (mm) overjet and 2 mm overbite. She is currently in orthodontic appliances to correct her malocclusion but the health plan denied the claim due to a lack of medical necessity. The panoramic radiograph supplied indicates 2 supernumerary premolars in the mandibular left quadrant and an impacted tooth 21. At issue is the medical necessity of braces and monthly visits. 

There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, overjets greater than 6 millimeters (mm) are shown to negatively affect the oral health quality of life of patients. (3) For these reasons, treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression/social isolation
Treatment: Increasing the Social Day Care (SDC) from 2 to 3 days/week
The insurer denied coverage for: Increasing the SDC from 2 to 3 days/week
The denial is: Overturned
This is an adult with chronic medical problems including hypertension, diabetes and heart disease. The patient lives with their spouse, daughter and son-in-law. The daughter and son-in-law are paid and informal caregivers. The patient is currently receiving consumer directed personal assistance services (CDPAP) service 4 days/week, 5 hours/day (20 hours/week) and SDC services 2 days/week (combined total services of 28 hours/week).  

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent. The patient requires extensive to maximal assistance for performing much of their Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires limited assistance for bathing, lower body dressing, toilet transfer/use and ambulation. The patient is otherwise independent with personal hygiene, upper body dressing, bed mobility and eating. The patient reports being frequently incontinent of bladder and continent of bowel. There has been no change regarding the patient's ability to perform activities of daily living or self-sufficiency over the prior 90 days. The patient's cognitive and functional ability are much the same when compared to the UAS report.

The letter from the patient's treating physician describing their clinical condition and request for "social day care services" was reviewed.  The doctor does not provide the associated treatment notes to support his claim that the patient "Is socially isolated which led to depression and isolated feeling." There is no clinical evidence that the lack of social day care services is the etiology of the patient's reported depression. However, this physician would agree that an additional 4 hours of social day care would be beneficial for the patient (i.e., socialization, decreased isolation and participation in structured activities) particularly given that the patient's spouse also participates in SDC 3 days/week. This physician is also persuaded by the other appeal letter; who eloquently describes the emotional and practical benefits of the SDC program for the patient. Based on the documents reviewed, increasing the SDC from 2 to 3 days/week is medically necessary.  

From a physical medicine and rehabilitation perspective, increasing the SDC from 2 to 3 days/week is medically necessary.  

Based on the above, the insurer's denial must be reversed. 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 Social Day Care (SDC) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary tract infection, pyelonephritis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
This is an adult patient with a past medical history significant for colon cancer, lupus, and depression who presented to the emergency department (ED) with complaints of fever, body aches, and left flank pain.

Vital signs on presentation included: Temperature - 102.2 degrees Fahrenheit, Blood Pressure 112/68, Pulse - 58, Respiratory Rate - 18, oxygen (O2) saturation 98% (percent). Laboratory results included the following: White blood cell count (WBC) - 13.36k, hemoglobin (Hgb) -11.8, hematocrit (Hct) - 35.1, creatinine - 0.6, glucose - 106, lactate - 0.8.

The patient was started on intravenous (IV) fluids and empiric antibiotics (Ceftriaxone) for possible urinary tract infection (UTI). Computed tomography (CT) scan of abdomen/pelvis showed pyelonephritis. The patient remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient follow-up on oral antibiotics. 

According to documentation, the patient was admitted for urinary tract infection. The patient was febrile (102.2 F), and laboratory results were notable for elevated WBC (13.36k), despite outpatient treatment with oral antibiotics. Based on above findings, in a high-risk patient with history of colon cancer, hospital admission was medically necessary.  

Based on the above, the insurer's denial must be reversed. 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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic atrial fibrillation, heart failure, coronary artery disease, hypertension, diabetes, gastroesophageal reflux disease (GERD), gout, and hyperlipidemia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult male patient was hospitalized for an elective pulmonary vein isolation procedure. His past medical history was significant for persistent symptomatic atrial fibrillation, heart failure, coronary artery disease, hypertension, diabetes, 
gastroesophageal reflux disease (GERD), gout, and hyperlipidemia. The patient was taken to the catheter lab and underwent successful pulmonary vein isolation atrial fibrillation ablation and cavo-tricuspid isthmus ablation procedures. There were no procedural-related complications. The patient was observed overnight and discharged to home the following day. 
The requested coverage for the service Inpatient Hospital Admission was denied based on policy, and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, criteria for inpatient admission were not met, including hemodynamic instability, respiratory distress, pulmonary edema, monitoring of patients discontinuing antiarrhythmic agents before electrophysiologic study, patients undergoing catheter ablation for ventricular tachycardia, complex cases requiring next-day electrophysiologic study, heart block, placement of permanent pacemaker required when atrioventricular node procedures result in heart block or procedure complications, including arrhythmias, thromboembolic event, shock, aortic valve injuries, air embolism, cardiac arrest, esophageal perforation, phrenic nerve injury, coronary artery occlusion, major bleeding at vascular access site and cardiac tamponade. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received for a routine, uncomplicated pulmonary vein isolation atrial fibrillation ablation like in this case is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian carcinoma. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The denial is upheld. 

The patient is an adult female. She underwent a robotic assisted total laparoscopic hysterectomy, bilateral oophorectomy, bilateral salpingectomy, omentectomy, lymph node removal, and cystoscopy for ovarian carcinoma. The surgery was uncomplicated. The patient was kept overnight. Her pain was well controlled. By the next day she was voiding, tolerating a diet, and ambulating; pain was well controlled. She was discharged home on the next day with follow up in one to two weeks. 
The inpatient hospital stay was denied coverage by the health plan as not medically necessary. The denial is being appealed. 

The inpatient admission was not medically necessary. 

According to American College of Obstetricians and Gynecologists, "The ERAS (enhanced recovery after surgery) principles represent an evidence-based approach to surgical management that challenges traditional surgical management paradigms. The use of ERAS [enhanced recovery after surgery] pathways has resulted in more rapid surgical recovery, shorter length of stay, greater patient satisfaction, and decreased costs when compared with traditional approaches. These benefits have been replicated across the spectrum of gynecologic surgeries, including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the ERAS [enhanced recovery after surgery] program requires collaboration from all members of the surgical team. Successful ERAS [enhanced recovery after surgery] pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems, and the use of ERAS [enhanced recovery after surgery] pathways should be strongly encouraged within institutions." An outpatient observation bed is an alternate level of healthcare comprising of short stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient. The patient in question was taken to the operating room and underwent an uncomplicated procedure. After surgery she was not ready for discharge same day. She required observation and nursing care to assist with her ambulation and medical management of her pain. Based on the procedure performed and standards of care, it would not have been expected that inpatient care would be required, as this is typically managed at a lower level of care. Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided at a lower level of care.