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

Diagnosis: Low back pain
Treatment: On campus-outpatient hospital/surgical care Intracept Procedure
The insurer denied coverage for on campus-outpatient hospital/surgical care Intracept Procedure
The denial is upheld.

The patient is an adult with a history of low back pain x two years. Prior treatment has included home exercises, lumbar epidural steroid injections, medications, physical therapy and a spinal cord stimulator. The patient's pain varies between 7/10 and 10/10. A magnetic resonance imaging (MRI) showed mixed modic type 1 and 2 changes at the lumbar (L)5 - sacral (S)1 disc space level. The MRI shows no change compared to prior studies.

A request has been made for the patient to undergo an Intracept Procedure. This was previously denied. The denial is being appealed. The basis for the appeal is a quote from the International Society for the Advancement of Spine Surgery.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome for the requested procedure, an on campus-outpatient hospital/surgical care Intracept Procedure to treat chronic vertebrogenic pain. "There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN (basivertebral nerve ablation). Non-industry funded high-quality, large prospective studies are needed to confirm these findings" (Conger, A. et al. 2021).
A magnetic resonance imaging (MRI) showed mixed modic type 1 and 2 changes at the L5-S1 disc space level. The MRI shows no change compared to prior studies. The use of this procedure is not considered the best available treatment for this patient at this time. Based upon the findings on the MRI, further procedures such as the Intracept procedure would not be of benefit to the patient. 

"According to the American Pain Society, surgical referral should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year. However, there is mixed evidence, for some of the most commonly performed invasive procedures such as injection therapy of the epidural space, facet joints, or local sites, spinal fusion, or lumbar disk replacement" (Casiano, V. E. et al. 2021).

In summary, the denial of on campus-outpatient hospital/surgical care Intracept Procedure to treat chronic vertebrogenic pain and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Inpatient Hospital Admission:
The insurer denied: Inpatient Hospital Admission:
The denial is upheld.

The patient is an adult male with a past medical history of hypertension, hyperlipidemia, and tobacco.  The patient presented to the emergency department for evaluation of hemoptysis.  On arrival to the emergency department, the patient was afebrile and hypertensive with a blood pressure of 212/108.  He was given losartan and hydralazine with improvement of his blood pressure.  Labs showed a sodium of 142, potassium of 3.6, creatinine of 0.7, hemoglobin of 14, and platelet count of 280.  Chest x-ray did not demonstrate any acute cardiopulmonary abnormalities.  Computed tomography scan of the chest did not demonstrate evidence of pulmonary embolism or aortic dissection.  

The patient was admitted to the inpatient unit for treatment of hypertensive urgency.  He was started on losartan and Procardia with gradual improvement.  He did not have any further episodes of hemoptysis during the hospitalization.  He was ultimately discharged with outpatient follow-up.

The proposed inpatient hospital admission was not medically necessary.

The patient was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of pulmonary embolism or aortic dissection. The patient did not have evidence of hypertensive emergency/encephalopathy. He did not have further episodes of hemoptysis and his hemoglobin was stable. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.  A lower level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Left-sided weakness, difficulty standing and walking, and memory deficit.
Treatment:  Increase Personal Care Aide (PCA) Services, Level II: 12 Hours/Day, 7 Days/Week; 12 Hours/Day, 7 Days/Week; For a Total of 168 Hours/Week.

The insurer denied the increase in PCA services, level II: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week; for a total of 168 hours/week.  The denial is overturned.

The patient is an elderly male.  The patient's Uniform Assessment System describes the patient's cognitive skills as minimally impaired; the patient is alert and oriented times three.  The patient requires maximal assistance to total dependence with meal preparation and managing medication; the patient requires extensive to total assistance in activities of daily living.  The patient has left-sided weakness, difficulty standing and walking, and memory deficit.  The patient cannot stand; he uses a Hoyer lift with two-person assistance to transfer from the bed to the wheelchair.  The patient is frequently incontinent for bladder and bowel.  

Currently, the patient has personal care aide (PCA) level II: 9 hours/day, 7 days/week, 63 hours/week.  The request is to increase PCA services for a total of 168 hours/week.

The proposed treatment is medically necessary.

Based on the records reviewed, the patient is bedridden and has pressure ulcers.  The patient is bladder and bowel incontinent.  The patient requires a Hoyer lift to move from the bed to the wheelchair with two-person assistance.  The patient only has his wife at night for assistance.  Therefore, the requested 24 hours/day care, 7 days/week, for a total of 168 hours/week, is medically necessary and appropriate.

The split shift is needed to provide enough care for the patient who requires turning every two-three hours as the patent is bedridden with pressure sores.  The current PCA level II: 9 hours/day, 7 days/week, 63 hours/week is not enough to provide enough care for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain
Treatment: Inpatient Hospital Admission 
The insurer denied the inpatient hospital admission. 
The denial is upheld.

The patient is an adult male. He was hospitalized for abdominal pain and vomiting. He presented to the hospital ED (emergency department) for evaluation of belly pain and vomiting for 1 day. His PMH (past medical history) was noteworthy for known GERD (gastroesophageal reflux disease)/gastritis treated with antacids. The patient's BP (blood pressure) was 150/88. The patient's troponin was marginally elevated at 0.08, and there were no diagnostic EKG (electrocardiogram) changes for ischemia or AMI (acute myocardial infarction). Treatment included IV (intravenous) fluids, IV Pepcid followed by oral PPI (proton pump inhibitors), and he was discharged to home. This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

The inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature and this reviewer's expert medical opinion, the documentation submitted for review does not establish the requested acute inpatient hospital stay was medically necessary for this patient. There was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria were not met, including hemodynamic instability, respiratory distress, acute myocardial infarction, hypertension requiring inpatient hospitalization, dehydration, sepsis, SBO (small bowel obstruction), GIB (gastrointestinal bleeding), acute pancreatitis or cholecystitis, impending surgery needed, remaining, persisting vomiting requiring keeping the patient NPO (nothing by mouth) after observation or any other medical condition that warranted inpatient hospitalization. The care he received for an uncomplicated gastroenteritis like in his case is routinely provided safely and effectively at a lower level of care. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. Therefore, based on the submitted information and the current standard of care, the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophagitis and a 4 centimeter (cm) hiatal hernia.
Treatment: Current Procedural Terminology (CPT) code 43282.
The insurer denied coverage for CPT code 43282.
The denial is overturned.

This is the case of an adult male with a history of gastroesophageal reflux disease (GERD) and hypertension (HTN). As per the History and Physical, the patient has been doing well with no changes in his symptoms. He is on Protonix and Carafate. His repeat esophagogastroduodenoscopy (EGD) with manometry demonstrated resolution of esophagitis and still with a 4 cm (centimeters) hiatal hernia. Manometry was somewhat abnormal. The provider had a lengthy discussion with the patient and given his recurrent esophagitis, GERD on esophagram and hiatal hernia on EGD with ongoing use of proton pump inhibitor (PPI), he believes it is a good idea to proceed with the hiatal hernia repair with fundoplication. The patient underwent robotic assisted lap repair of hiatal hernia. Post op, the patient did well, and the provider noted that the patient was to get clears with anticipation of discharge in 24 hours. Progress indicated that the patient was having some pain with deep inspiration which was felt to be due to insufflation of the mediastinum to expose the hiatal hernia. This is also the cause of the subcutaneous crepitus. A full liquid diet was ordered. He was discharged later. 

The patient has reflux and has been treated with proton pump inhibitors for years and has a 4 cm paraoesophageal hiatal hernia as noted by the provider. According to the provider the patient has Class C esophagitis in the past and therefore given the continuation of symptoms from his GERD requires a fundoplication to prevent the complications of a Barrett's esophagus. 

According to Milliman Care Guidelines (MCG) Health Inpatient and surgical care 26th Edition. Fundoplasty, esophagogastric, by laparoscopy, procedure is indicated for 1 or more of the following: Symptomatic GERD (e.g., heartburn, regurgitation, dental erosions, cough attributable to reflux) unresponsive to, or intolerant of, medical therapy; Symptomatic GERD with moderate to severe erosive esophagitis (e.g., LA [Los Angeles] grade B or higher); Surgical treatment of GERD preferred to anticipated long-term medical  treatment; GERD with development of Barrett esophagus with metaplasia or low-grade dysplasia, stricture, or esophageal ulcer; Treatment of GERD after endoscopic therapy of Barrett esophagus with high-grade dysplasia, carcinoma in situ, or mucosal carcinoma; In conjunction with esophageal myotomy in patient with achalasia; Incarcerated or strangulated hernia; Gastric volvulus; Paraoesophageal hernia; Repeat surgery for failed previous anti reflux or hiatal hernia procedures. Thus, based upon MCG guidelines the patient has met criteria for fundoplasty. 
			
Based on the above, the insurer's denial is 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 CPT code 43282 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-ST (interval on EKG [electrocardiogram] elevation myocardial infarction.
Treatment: Hospital Interfacility Transfer.
The insurer denied coverage for hospital interfacility transfer.
The denial is overturned.

The patient presented to the hospital with palpitations and shortness of breath.  The patient work up revealed atrial fibrillation (AF) with rapid ventricular rates of 170 beats per minutes (bpm) and hypotension. Serum troponin was elevated, and the patient was diagnosed with non-ST (interval on EKG) elevation myocardial infarction. Past medical history was significant for myocardial infarction and cardiac arrest, Medtronic implantable cardiac defibrillator, atrial fibrillation status post radiofrequency.  Recommendations were made for the patient to undergo electrophysiologic study (EPS) and ablation of atrial fibrillation. Given that previous cardiac procedures, including ablation, were performed at another hospital, the patient requested a transfer to that institution. Upon arrival he was noted to have a low-grade fever and was COVID (coronavirus) positive. He was also treated for lower extremity cellulitis and stabilized.  Ultimately, he underwent redo AF ablation and was discharged.

This patient had a history of AF ablation and redo AF ablation and was previously followed by physicians at another hospital. After presenting with recurrent atrial arrhythmia with heart rates of 170 bpm, hypotension and non-ST elevation myocardial infarction, a decision was made to recommend electrophysiologic study and ablation.  As previous ablation lesion sets involved the pulmonary veins, posterior wall, coronary sinus, mitral isthmus, and intercaval areas, a redo ablation would require a tertiary care center with expertise in complex ablation. Because this patient was known and previously treated at one hospital, and the recurrence of atrial fibrillation post ablation results in a more complex procedure, it is to the patient's clinical benefit to have the procedure done at the original center.  In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, 20% (percent) of patients undergoing ablation were hospitalized for more than a single day (Reference 2,3) Hosseini noted that patients undergoing complex ablation, such as ablation of atrial fibrillation, were more likely to have complications requiring hospital admission with an increased length of stay (Reference 4). In conclusion, interfacility transfer was medically necessary and in the best interest of the patient.

Based on the above, the insurer's denial must be overturned. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hospital interfacility transfer is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis involving the left chest wall. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female. She was hospitalized for cellulitis involving the left chest wall. She presented with chest wall pain at the site of her recently inserted internal loop recorder (ILR), despite three days of outpatient oral clindamycin. Her past medical history includes previous bacteremia complicated by osteomyelitis. The patient's treatment included IV (intravenous) antibiotic and removal of the ILR (internal loop recorder). Telemetry monitor reported the nonsustained 10 beat VT (ventricular tachycardia) episode. A PICC (peripherally inserted central catheter) line was placed by IR (interventional radiology), and she was receiving IV (intravenous) Dilaudid and IV (intravenous) Benadryl for pain management. A MRI (magnetic resonance imaging) of the chest wall was negative for osteomyelitis and she was discharged to home the next day. 

The inpatient hospital admission was not medically necessary. 

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the MCG (Milliman Care Guidelines) guidelines for Cellulitis, criteria for inpatient admission are not met, including sepsis, very high fever, persisting confusion, hemodynamic instability or tissue ischemia/necrosis with risk of loss of limb or body part. There was no complication like stroke, endocarditis, osteomyelitis, respiratory distress, pulmonary edema, pulmonary embolism, acute myocardial infarction, life-threatening cardiac arrhythmia of immediate concern, hospital acquired pneumonia or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. 

In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past a lower level of care. The care the patient received, including IV (intravenous) antibiotics and removal of the ILR (internal loop recorder) for uncomplicated cellulitis, 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 inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Increase Home Care/Personal Care (HHC) Personal Care Aide (PCA): Live-In to 24 Hours/Day (Split Shift)
The insurer denied an increase in HHC PCA: Live-In to 24 hours/day (split shift).
The denial is overturned.

The patient is an older adult female who underwent a follow-up clinical assessment utilizing the Department of Heath's Uniform Assessment System tool. Noted was some change of physical functioning since the previous assessment and change in abilities to perform physical functions such as bed mobility, bathing, personal hygiene, dressing upper and lower body, walking, eating, meal preparation, ordinary house work and medication management. The patient's memory is noted to be okay. She does have bladder incontinence. Cognitively, the patient is minimally impaired. She does have some memory problems; she usually understands verbal and nonverbal contact, however she has difficulty finding words or finishing thoughts but if given time, she can comprehend. The patient is forgetful of date. She is mostly wheelchair bound; a stroke affected the left side of her body and speech. The patient had an unsteady gait. The request is for an increase in home care/personal care HHC (home health care) personal care aide (PCA) from live-in per diem to 24 hours/day (split shift).

The proposed increase in home care/personal care HHC PCA: live-in to 24 hours/day (split shift) is medically necessary.

The patient is an older adult female who is wheelchair bound, with urinary incontinence and weakness in her left side of the body. The patient is unable to ambulate; she has lower extremity weakness and she cannot self-propel. The patient is completely dependent for all her activities of daily living. The patient requires assistant to get out of bed. The patient requires heavy verbal cues to direction to wheelchairs. The patient requires assistance to transfer to the toilet, and she needs help returning to bed. The request is for two providers; 12 hour shifts (split shift) for the aids is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple Sclerosis.
Treatment:  Environmental Stairlift.

The insurer denied Environmental Stairlift.  The denial is overturned.

The patient is an adult female with Multiple Sclerosis, causing significant functional deficits with activities of daily living (ADLs) and mobility. She requires maximal to total assistance with all ADLs (activities of daily living) and mobility. She was ordered a stair lift to help her caregivers be able to take her to the second floor. Coverage for the stair lift was denied by the health plan. This denial is being appealed.

The the requested stair lift is medically necessary.

According the provided medical documentation, the patient has a past medical history of multiple sclerosis, causing significant functional deficits with activities of daily living (ADLs) and mobility. She requires maximal to total assistance with all ADLs (activities of daily living) and mobility. Due to her limited mobility, she cannot access the second floor, which has a handicap accessible bathroom.

Therefore, given the above, the requested stair lift is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eosinophilic Esophagitis and Duodenitis
Treatment: Inpatient emergency admission
The insurer denied coverage for an inpatient emergency admission.
The denial is upheld.

The is a patient with a history of end stage renal disease (ESRD) on dialysis, anemia, depression, and hypertension. The patient was brought in by emergency medical services (EMS) with complaints of right lower quadrant abdominal pain with nausea and vaginal spotting for 2 days. A Computed tomography (CT) of the chest and abdomen revealed streaky airspace opacities throughout the lungs, a left dialysis catheter terminating in proximal inferior vena cava, cholelithiasis with mild gallbladder wall thickening, mild edema in the periportal region, mild hepatomegaly, gallbladder sludge and small stones, and small, hyperechogenic right kidney consistent with parenchymal disease with cysts. Her pelvic ultrasound showed a 2.1 centimeter (cm) fundal submucosal myoma. The patient was admitted for continuous monitoring of vaginal bleeding under Gynecology services, repositioning other permacath with Interventional Radiology (IR) services, and an esophagogastroduodenoscopy (EGD) performed with Gastroenterology services, which revealed esophageal mucosal changes suspicious for eosinophilic esophagitis and duodenitis. The patient's condition improved and was discharged.

The services provided could have been rendered at a lower level of care such as an observation level. Many of the services, such as the endoscopy, could have been rendered as an outpatient.

Despite the patient's presentation, the care provided could have been rendered in its entirety at a lower level of care. The patient had an infection causing gastroenteritis; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias, or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.

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 inpatient emergency admission services is not substantiated.