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

Diagnosis: back pain.
Treatment: Thermal destruction of intraosseous basivertebral nerve.  
The insurer denied Thermal destruction of intraosseous basivertebral nerve. The health.plan's determination is upheld.

The patient is a female with complaints of low back pain. The pain began many years ago. Prior treatment has included chiropractic care, lumbar injections, medications, as well as other modalities. The pain continues despite multiple treatments. The pain limits activities of daily living (ADL). Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic changes at disc spaces L (lumbar) 3-L4. 

The Thermal destruction of intraosseous basivertebral nerve 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. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Orthopedic
Pain Management

Diagnosis: back pain.
Treatment: Thermal destruction of intraosseous basivertebral nerve.
The insurer denied Thermal destruction of intraosseous basivertebral nerve. 
The health plan's determination is overturned. 

This patient is a female who has a long-standing history of chronic low back pain. Her pain is constant aching, sharp and burning with intermittent radiation to bilateral hips. Pain level is 6/10. Her pain is exacerbated by working as a paramedic and horseback riding. She had tried physical therapy (PT), chiropractic manipulation and pain medications, none of which provided her with adequate pain relief. Physical exam (PE) was remarkable. Magnetic resonance imaging (MRI) showed degenerative endplate changes at L (lumbar) 3/4 with multilevel degenerative disc disease.

Thermal destruction of intraosseous basivertebral nerve is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrated the sustained improvements in pain and function of this intervention for patients with vertebrogenic pain. This patient had failed extensive treatments pain medications, physical therapy (PT) and chiropractic manipulation. Her pain is severe enough with a negative impact on her quality of life (QOL) and activities of daily living (ADL). Further interventions are indicated to improve her pain and function. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is likely to be more beneficial than any standard treatments for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-Uterine Artery Embolization Syndrome 
Treatment: Inpatient hospital admission 
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 

This is a patient with a diagnosis of symptomatic fibroid uterus who underwent a uterine artery embolization (UAE) and who presented to the emergency department (ED) with nausea and vomiting for 4 days. The patient endorsed abdominal pain to the right lower quadrant pain and constipation. The patient had difficulty tolerating oral intake. A computed tomography (CT) scan and pelvic ultrasound did not reveal any acute condition. The patient was admitted for pain control and hydration. 

UAE is a nonsurgical treatment option for premenopausal women with bothersome fibroid-related symptoms who wish to retain their uterus, escape side effects associated with prolonged medical therapy, and avoid surgery (e.g. ["for example"], myomectomy). 

Virtually all women experience post-procedure pain, which is believed to be due to ischemia of the fibroids and uterus. The degree of pain ranges from mild to severe cramping. Options for pain control depend on the severity and include patient-controlled analgesia, oral or parenteral opiates, and nonsteroidal anti-inflammatory drugs. Intravenous conscious sedation during the procedure followed by PCA (patient-controlled analgesia) suffices for postprocedural pain management. 

Following the procedure, most women experience postembolization syndrome, which consists of pelvic pain and cramping, nausea, vomiting, fever, fatigue, myalgias, malaise, and leukocytosis. These symptoms occur within the first 48 hours of the procedure and gradually improve over seven days. Patients who do not gradually improve should be evaluated for other conditions, such as sepsis. 

UAE is usually performed as an outpatient procedure. One study showed that with defined telephone follow-up, staff availability, and a protocol designed to alleviate the post-procedure constitutional symptoms, UAE is both safe and effective when performed as an outpatient procedure. PCA, oral or parenteral opiates, nonsteroidal anti-inflammatory drugs, antipyretics, and antiemetics can be started preemptively in the recovery room. 

This patient was stable and their pain was consistent with postembolization syndrome. The patient's pain and symptoms could have been controlled as an outpatient. Nothing was done in the hospital that could not have been done as an outpatient (analgesics and antiemetics). 

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

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

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

The patient is a male with a medical history of hypertension, hyperlipidemia, and previous deep vein thrombosis who was admitted due to left lower extremity cellulitis. The admission was prompted by a one-week duration of progressive redness and warmth in the left leg. The patient's treatment began one day before his presentation with the administration of oral Linezolid. An X-ray of the left tibia and fibula raised concerns about possible osteomyelitis in the distal left tibia, leading to a decision to perform a magnetic resonance imaging (MRI) of the left leg. 

The inpatient hospital stay was not medically necessary for this patient. 
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Upon reviewing the medical records, there was no indication that the patient met any of the criteria justifying admission to the acute inpatient level of care for cellulitis treatment. Therefore, opting for a brief period of observation was a sensible decision. This approach aimed to ensure a favorable response to antibiotics and to facilitate the determination of appropriate antibiotic treatment following discharge.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: knee surgery. 
Treatment: Pneumatic Compression Device. 
The insurer denied a Pneumatic Compression Device. 
The health plan's determination is upheld. 

The patient is a male who underwent elective left knee arthroscopic surgery for partial medial meniscectomy and chondroplasty of the trochlea and medial femoral condyle. The patient was prescribed home use of intermittent limb compression devices for the prevention of deep vein thrombosis. 

The Pneumatic Compression Device is not medically necessary for this patient. The patient underwent a routine left knee arthroscopic surgery and was prescribed home intermittent limb compression devices in addition to his use of oral Xarelto for the prevention of deep vein thrombosis. Based upon the peer-reviewed literature published in the American Journal of Sports Medicine, the chemoprophylaxis with Xarelto was appropriate for this patient to prevent deep vein thrombosis (DVT) after routine arthroscopic knee surgery. The addition of limb compression devices in this case was not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth Hormone Deficiency. 

Treatment: Genotropin. 

The insurer denied coverage for Genotropin. 

The denial is overturned. 

The patient is diagnosed with Growth Hormone Deficiency (GHD). This request is for Genotropin. The patient's growth hormone (GH) stimulation test with clonidine and arginine peaked at 9.41. The patient's bone age was 14 years 3 months at calculated age (CA); subsequently, the patient's bone age was 14 years at CA. The patient's height velocity is reported to be 3.36 centimeters (cm)/year (yr). The patient's testes were 12-15 cubic centimeters (cc) bilaterally and pubic hair was at tanner 3. The patient's insulin-like growth factor 1 (IGF1) was 294. The patient's weight was 138.5 pounds. 

The patient's height  was 160.02 cm (-1.77 standard deviations (SDS)) and  was 163 cm (-1.71 SDS) with height velocity over 1 year 1 month of 2.6 cm/yr. 

The patient's mid parental height is 175.26 cm (-0.22 SDS). 

The request is medically necessary. 

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below: 

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society(1), the Lawson Wilkins Pediatric Endocrinology Society(2,3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists(4). The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 standard deviation (SD) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 yr more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or insulin-like growth factor-binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10 nanograms (ng)/milliliter (ml).

The patient met height velocity criteria as height velocity over 1 year 1 month was 2.6 cm/yr which is greater than 2SD below the mean.  GH stimulation testing peaked at less than 10ng/ml (the patient's GH stimulation test with clonidine and arginine peaked at 9.41). 

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 Genotropin is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lightheadedness. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of a patient that presented to the hospital complaining of lightheadedness and left shoulder pain and swelling. Past medical history included hypertension. On arrival to the hospital the patient was hypertensive with a blood pressure (BP) of 174/109 and pulse was 86. On physical exam the patient was morbidly obese with a body mass index (BMI) of 50. Full range of motion of both shoulders was noted and no swelling appreciated. 12 lead electrocardiogram (ECG) was significant for sinus rhythm with non-specific T wave abnormalities. Serum blood testing revealed a mild elevation of high sensitivity troponin 38.5. The patient was admitted for additional testing and treatment. Telemetry revealed no abnormality. The patient signed out against medical advice (AMA). 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical chest /shoulder pain and a past medical history of hypertension. The patient's pretest probability of coronary artery disease was low (1). Utilizing the HEART (History, ECG, Age, Risk Factors, Troponin) score the patient was considered low risk (2). Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was 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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right peritonsillar abscess 
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a man with multiple medical problems who was admitted with a sore throat, odynophagia, and right ear pain. Evaluation in the emergency department (ED) revealed a right peritonsillar abscess by computed tomography (CT) scan. He was admitted for evaluation and treatment. Admission vitals were temperature 97.9, respirations 18, and blood pressure 105/64.
Treatment consisted of clindamycin in the emergency department, intravenous (IV) fluids, and Unasyn and vancomycin after the methicillin-resistant staphylococcus aureus (MRSA) screen returned positive. An infectious disease specialist was consulted, who reviewed the case and recommended continuing Unasyn and vancomycin.

The inpatient hospital admission was not medically necessary.
The provided documentation describes the patient with tonsillar enlargement, which was read as a possible peritonsillar abscess per CT of the neck. An expert ENT (Ear Nose Throat) evaluation within 24 hours of admission determined the patient does not have a drainable abscess, and treatment should consist of antibiotic therapy and corticosteroids. After initiating antibiotics and corticosteroids, the patient showed significant improvement and was safely discharged home within 24 hours. Nationally recognized guidelines for treating tonsillitis with peritonsillar phlegmon recommend an observation level of care treatment to determine whether the patient needs inpatient admission or can be released to ambulatory care treatment. Given that the patient improved the symptoms, no inpatient criteria were satisfied.
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 has a past medical history significant for metastatic colon cancer, status-post surgery, chemotherapy and radiation who presented to the emergency department with complaints of fever and right-sided abdominal discomfort following a recent liver biopsy. 
 
Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 139/92, Pulse 73, Respiratory Rate 18, oxygen (O2) saturation 99% on Room Air. Laboratory results included the following: white blood cell count (WBC) 6.8, hemoglobin (HGB) 13.8, creatinine 1.11, glucose 73, C-reactive Protein (CRP) 8.7, and lactate 2.2.

Patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for suspected infection. Chest X-ray (CXR) was negative. Infectious Disease consulted and adjusted antibiotic coverage. Cultures remained negative. A computed tomography (CT) scan of abdomen/pelvis revealed an 11 x 9.1 centimeter (cm) right hepatic mass that was unchanged. Antibiotics were discontinued. Patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics as an outpatient.

According to documentation, patient presented with abdominal discomfort following a recent liver biopsy. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. Area of biopsy was described as "looks clean and dry, no surrounding erythema/pus drainage." Patient had no evidence of disseminated infections and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management. 

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

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

This is an adult female with a history of substance use disorder, alcohol use disorder, anxiety, insomnia, gastroesophageal reflux disease (GERD), myocarditis, and pericarditis. She was brought into the emergency room by emergency medical services for right upper quadrant (RUQ) pain associated with diarrhea, nausea, vomiting, and chest discomfort. 
On the day of admission, the patient had right upper quadrant pain that she described as "throbbing and painful" associated with nausea, vomiting, and diarrhea for 15 days. She was unable to tolerate food / drinks. She used Zofran with no relief. Alanine aminotransferase (ALT) was 214, aspartate aminotransferase (AST) was 298, alkaline phosphatase was 113, and lactate was 2.3. On day #2, the patient persistently complained of abdominal pain and refused oral medications. The patient was anxious as well as agitated. Clinical Institute Withdrawal Assessment (CIWA) score was 11. The patient was treated with intravenous fluids and intravenous medications including Benadryl, Pepcid, Dilaudid, Toradol, morphine, Ofirmev, Ativan, Versed, magnesium sulfate, Zofran, Protonix, and thiamine. On day #3, the patient left against medical advice.

The requested health service was medically necessary.

On day of admission, the patient had right upper quadrant pain that she described as "throbbing and painful" associated with nausea, vomiting, and diarrhea for 15 days. She was unable to tolerate food / drinks. She used Zofran with no relief. Alanine aminotransferase (ALT) was 214, aspartate aminotransferase (AST) was 298, alkaline phosphatase was 113, and lactate was 2.3. The patient had an elevated Clinical Institute Withdrawal Assessment (CIWA) score of 11 (moderate withdrawal) on day #2. The patient required treatment with intravenous (IV) fluids, intravenous Benadryl, intravenous Pepcid, intravenous Dilaudid, intravenous Toradol, intravenous morphine, intravenous Ofirmev, intravenous Ativan, intravenous Versed, intravenous magnesium sulfate, intravenous Zofran, intravenous Protonix, and intravenous thiamine. The medical records do support that the acute inpatient admission was medically necessary. The patient did require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was medically necessary for the dates of service in question as it required the intensity of the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral vascular disease
Treatment: Outpatient services (peripheral revascularization)
The insurer denied the outpatient services (peripheral revascularization).
The denial is overturned.

This patient is an adult male. He presents with recurrent, debilitating right leg claudication due to peripheral vascular disease. He originally presented with right leg claudication last year. He underwent right superficial femoral artery (SFA) stenting. His symptoms resolved, and his ankle-brachial index (ABI) improved to a normal value, 1.06. However, follow-up evaluation 5 months ago showed that his ankle-brachial index had fallen to 0.49. His symptoms had recurred. The provider has recommended repeat endovascular treatment for the right leg, because of the likelihood that the SFA stent has re-stenosed.

The proposed treatment is medically necessary.

The record shows that the patient has developed recurrent right leg claudication after successful endovascular treatment of right SFA occlusion last year. His ABI has declined substantially in the interim between the procedure last year and the visit 5 months ago, when the patient reported recurrent symptoms (from 1.06 to 0.49). The most likely explanation of this decline and the recurrent symptoms is re-stenosis or re-occlusion of the right SFA stent. Angiography and redo intervention are medically necessary in this setting. It is not indicated to obtain an imaging study, such as a computed tomographic angiography (CTA), to demonstrate the right SFA re-stenosis. Such a test would be an inappropriate use of medical resources and expose the patient to unnecessary radiation and risk of contrast-induced renal failure.