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

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

The patient is a male with new onset of chest pain, who presented to the emergency department (ED). The patient reported left sided diffuse sharp pain and a heavy feeling while playing basketball. The pain was associated with palpitations. The pain was graded 8/10. It was radiating to the stomach.

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with chest pain, and he had several coronary risk factors, including smoking and cocaine abuse. However, his work up was negative. Troponin was normal and stress test was normal. The patient did not have acute coronary syndrome. The patient did not require invasive procedures. His heart rate was slow, but not hemodynamically significant. The patient did not require any intravenous medications. The patient's renal indices (blood urea nitrogen (BUN) and Creatinine), were elevated upon presentation, but quickly recovered after hydration. His renal ultrasound was normal. His elevated liver enzymes most likely were due to alcohol consumption and were not specifically addressed during hospital stay. Based on above, the inpatient level of care was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who was admitted with chest pain. There was history of myocardial infarction and a stent. The blood pressure (BP) was mildly elevated, however, his other vital signs were normal. Troponin was negative. The electrocardiogram (ECG) was not acute. The creatinine was normal. He underwent a cardiac catheterization which demonstrated a patent left anterior descending (LAD) stent and severe very distal LAD PVD (peripheral venous disease) filling with collaterals. He was medically managed, a nitrate was added, he remained stable and was discharged.

The inpatient hospital admission was not medically necessary. This patient presented with chest pain and remained stable. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident (CVA)), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG.

In this case an acute inpatient level hospitalization was not medically necessary. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: urinary tract infection.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

This case involves a female with no significant medical history who presented to the emergency department with urinary frequency and abdominal pain. The symptoms were localized to the lower abdomen and dull in nature. The patient has a history of nephrostomy tube placement for kidney stones, and the concern was for recurrent kidney stones. On examination, the patient was afebrile, with slight tachycardia and normal blood pressure. She looked uncomfortable, with the abdominal exam showing tenderness to the left lower quadrant and right lower quadrant. The rest of the exam was fairly unremarkable. The patient had recently been diagnosed with a urinary tract infection in the outpatient setting and treated with Bactrim; however, the symptoms worsened, and she was experiencing some chills. 

The requested inpatient hospital admission is medically necessary for this patient. The patient has sepsis, as evidenced by systemic inflammatory response syndrome (SIRS), with positive lactic acid level, borderline low blood pressure, tachycardia, and two separate infections, requiring broad-spectrum antibiotic treatment. Within the first 24 hours, there was not any improvement in the patient's condition, requiring multiple doses of pain medications, no significant improvement in the leukocytosis, IV(intravenous) fluid requirement, and decreased ability to tolerate oral medications due to facial cellulitis caused by odontogenic infections. Treatment for this condition requires an inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral; and 64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The insurer denied: 64628: Thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral; and 64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The denial is upheld. 

The patient is an adult male that presented with a history of low back pain. The patient is status post L (lumbar) 4-5 right paramedian interlaminar epidural steroid injection earlier this year. 

The pain is 1-2/10. The patient is able to stand longer and walk farther. Overall function has improved. The patient continues with a home exercise program. The patient's lumbar exam revealed decreased range of motion and pain with flexion/extension and facet loading. Straight leg raise was positive on the right. Diagnosis includes vertebral genic pain, spinal stenosis lumbar region without neurogenic claudication, spondylosis of lumbosacral region without myelopathy or radiculopathy, DDD (degenerative disc disease) lumbar. 

The health plan should not cover the requested health service. 

Based on the documentation provided, the requested basivertebral radiofrequency ablation is not considered medically appropriate in this case. Although the patient has a history of low back pain with radicular symptoms, the most recent documentation provided noted that the patient's pain is 1-2/10 and the epidural steroid injection provided the patient with significant improvement with overall improvement in ADLs (activities of daily living). There is no indication as to why the procedure is needed at this time. Additionally, per the records, the patient was planned for a medial branch block, but there was no documentation of results. As such, the request is not considered medically appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral; and 64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The insurer denied: 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral; and 64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The denial is overturned. 

The patient is an adult male with a history of low back pain beginning several years ago. He has failed conservative management, including acupuncture, home exercises, lumbar epidural steroid injections, massage, physical therapy, and medication management with Aleve, Motrin, and Tylenol. The pain has had a significant impact upon ADLs (activities of daily living) such as sitting, sleeping, standing and walking. The severity of pain on VAS (Visual Analogue Scale) ranges between 1/10 and 7/10. 

The patient had an MRI (magnetic resonance imaging) that showed Modic type II changes at disc spaces L3/L4 and L4/L5, confirming vertebrogenic changes at L3, L4, and L5. 

The health plan should cover the requested health service. 

The requested health service or treatment more beneficial than any standard treatment for the insured's condition or disease. The standard treatments have failed to improve the patient's pain. The Intracept procedure is FDA (United States Food and Drug Administration) approved and there is enough data in the medical literature to show it is safe and effective in the treatment of vertebrogenic low back pain. A prospective, randomized, multi-center study by Khalil et al in 2019 and another prospective, 
randomized, multi-center study done by Fischgrund also in 2019 both presented high quality evidence of efficacy and safety of the procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.

Treatment: a procedure to treat low back pain (intraosseous basivertebral nerve ablation).

The insurer denied coverage for a procedure to treat low back pain (intraosseous basivertebral nerve ablation).

The denial is upheld.

This patient has had chronic low back pain for 2 years. He had physical therapy, home exercises and medial branch blocks. His pain medications include Cyclobenzaprine, Diclofenac, Gabapentin, non-steroidal anti-inflammatories (NSAIDs) and Tizanidine.  His magnetic resonance imaging (MRI) shows lumbar (L)2-L3 Disc herniation, L3-L4 disc extrusion with compression of the L4 nerve roots, and disc bulges at L4-L5 and L5-sacral (S)1.  The physician notes Modic changes at L3, L4 L5 and S1. The request is for basivertebral nerve (BVN) radiofrequency (RF) ablation at L3, L4, L5 and S1. There is no documentation of a surgical consultation or of Epidural Steroid injections (ESI).

The publications to date have been company sponsored and had methodology flaws.  There are no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al pointed out that all of the major studies while supportive, have been funded by the company: "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. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature: industry funding is a potential source of study bias for the available data reviewed, there are a limited number of studies, there is a short-term follow up for the majority of studied patients, and a unknown effect on the primary degenerative process.

Urits et al also commented on the need for more research on this promising technique:  "reproducible large RCTs (randomized control trials) 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 chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

This procedure is not likely to be more beneficial than the standard of care.

In summary, the denial for a procedure to treat low back pain (intraosseous basivertebral nerve ablation) 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 substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Diabetes, osteoarthritis, and dementia.

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week.

The insurer denied coverage for PCA Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week.

The denial is modified .

This is an elderly male with multiple medical problems including diabetes, osteoarthritis, and dementia. He lives with his spouse in a private home. The insurer approved PCA 3.5 hours/day, 5 days/week for a total of 17.5 hours/week. The request is for PCA Level 2: 12 hours/day - 7 days/week - a total of 84 hours/week.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Minimally impaired." He requires extensive assistance for lower body dressing, bed mobility, ambulation, and toilet transfers. Limited assistance is needed for personal hygiene, upper body dressing and toilet use. He is occasionally incontinent of bladder and continent of bowel. He is independent with eating. The patient's functional ability has declined compared to the previous UAS report. His condition and functional needs are not at a level, unpredictable or significantly declining as to require the requested personal care services (PCS) 84 hours/week. This physician would agree the patient may require additional monitoring. However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. Given his functional decline and based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the increasing PCA services 6 hours/day, 7 days/week, totaling 42 hours/week.  

From a physical medicine and rehabilitation perspective, PCA Level 2: 12 hours/day - 7 days/week - a total of 84 hours/week is not medically necessary. However, increasing PCA services 6 hours/day, 7 days/week, totaling 42 hours/week is medically necessary. 

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part. 

The medical necessity for PCA Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week services is modified to provide PCA services 6 hours/day, 7 days/week, totaling 42 hours/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperhidrosis
Treatment: Thoracoscopy with thoracic sympathectomy (32664)
The insurer denied: Thoracoscopy with thoracic sympathectomy (32664)
The denial is overturned.

The patient is an adult female with severe primary hyperhidrosis who has developed skin complications due to the same. The patient is being considered for bilateral thoracoscopic sympathectomy. She has tried and failed aluminum chloride (Drysol), Qbrexa, glycopyrrolate and numerous over the counter products. She has declined Botox.

The proposed thoracoscopy with thoracic sympathectomy (32664) is medically necessary.

The patient has an incapacitating illness that affects all aspects of her life including skin hygiene, ability to hold objects, etc. Further, the patient has developed fungal and bacterial skin infections in the past due to the excessive sweating. She has also developed a dermatitis and eczema condition due to excess sweating. The patient has tried and failed aluminum chloride (Drysol), Qbrexa, glycopyrrolate and numerous over the counter products. She has declined Botox. The thoracoscopic bilateral sympathectomy is medically necessary and curative in her case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Treatment: Qulipta
The insurer denied: Qulipta
The denial is: Upheld

The patient is a male who was prescribed Qulipta for treatment of "headache". Medical records indicate that the patient has had severe and frequent migraines since childhood. The plan denied Qulipta because there was not adequate use of injectable Calcitonin gene-related peptide (CGRP) inhibitors. The subject under review is the medical necessity for the use of Qulipta for this patient.

The health plan's determination is upheld.

Qulipta is not medically necessary. Qulipta is Food and Drug Administration (FDA) approved for prevention of episodic migraine. It is only literature supported for this indication as well. The diagnosis of episodic migraine does not appear in the medical record. Furthermore, the medical record suggests that the patient does not have episodic migraine, as the patient's migraines are noted to be frequent and severe. As such, it is not clear that Qulipta is being prescribed for an FDA approved or literature supported indication.
Additionally, there is no evidence that the patient has had an adequate trial of the plan alternative CGRP inhibitors Ajovy, Emgality, and Aimovig. All of these drugs are FDA approved for prevention of both chronic and episodic migraine. The plan has demonstrated that there was a 1 month fill for both Ajovy and Emgality and no fill for Aimovig. The medications may require more than 1 injection to significantly impact migraine frequent and/or severity. As such, it is reasonable that the patient is required to use the drug for at least 3 months prior to determination of therapeutic failure.
Qulipta is not medically necessary because it has not been established that the patient has an FDA approved condition for which Qulipta is used and the patient does not have an adequate trial or failure or contraindication to the available CGRP inhibitors that are FDA approved for his condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, diabetes, and arthritis
Treatment: Personal Care Services (PCS) 5 hours/day, 7 days/week, 35 hours total
The insurer denied coverage for PCS 5 hours/day, 7 days/week, 35 hours total.
The denial is upheld.

This is an adult patient with chronic medical problems including hypertension, diabetes, and arthritis. She lives alone in a 1-bedroom apartment. The insurer approved Personal Care Services (PCS) 5 hours/day, 5 days/week and 3 hours/day, 2 days/week, for a total of 31 hours/week and she is requesting PCS 5 hours/day, 7 days/week for a total of 35 hours/week which is currently under review.  

According to the Uniform Assessment System (UAS) report, the patient is fully alert and oriented. She is "self-directing and able to make needs known." The patient requires extensive assistance for bathing and lower body dressing; however, only limited assistance is needed for personal hygiene, upper body dressing, ambulation and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. She uses a walker for ambulation. She has essentially intact cognitive status and primarily limited functional impairments do not support the medical necessity of increasing PCS 5 hours/day, 7 days/week for a total of 35 hours/day. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the currently approved PCS 5 hours/day, 5 days/week and 3 hours/day, 2 days/week for a total of 31 hours/week combined with her attendance at social adult day care center 2 days/week.  

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient. The insurer's denial of coverage for PCS 5 hours/day, 7 days/week, 35 hours total is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

The patient is an elderly female. She was hospitalized from for chest pain. Her past medical history is significant for negative cardiac catheterization a year prior, hyperlipidemia and hypertension. She presented to the emergency department for evaluation of progressive chest pain from that morning with associated shortness of breath, nausea and vomiting. The patient's vital signs were remarkable for blood pressure 145/68, heart rate 119, afebrile, respiratory rate 20 and O2 (oxygen) saturation 98% on room air. She was in no distress. Her EKG (electrocardiogram) was considered low suspicion for AMI (acute myocardial infarction). She was also considered low suspicion for PE (pulmonary embolism) and aortic dissection. It was noted that she was not obtaining her blood pressure medications due to insurance issues, and she was simply put back on her metoprolol and amlodipine. Troponin panel is negative. Treatment included aspirin, subcutaneous Lovenox and a GI (gastrointestinal) cocktail. The request for coverage for inpatient hospital stay has been denied by the health plan as not medically necessary. The decision is being appealed.

The Inpatient Admission was not medically necessary.

Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, 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 Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism, aortic dissection or acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization 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 the observation period. The care that the patient received, including treatment for non-cardiac chest pain and suspected acute gastritis 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 inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: syncope.
treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), and rectal cancer status/post (s/p) resection and ostomy who was admitted with complaints of syncope. Vital signs were unremarkable. Physical exam was notable for dry mucous membranes, erythema above right eye, and ostomy with watery output. Lab work was notable for creatinine 2.86, elevated troponin, and a urinalysis (UA) + (positive) for infection. 

The inpatient hospital admission was medically necessary. This patient presented to the ED on with complaints of some increased ostomy output and subsequent fall and level of care (LOC), hitting her head. The lab work demonstrated significant acute kidney injury with an acute increase of creatinine to 2.86, which indicates a glomerular filtration rate (GFR) < (less than) 30. These findings are grossly abnormal, and concerning, in someone of this age without a known history of chronic kidney disease (CKD) and a baseline creatinine of 0.87. The patient required close monitoring for adverse sequela such as electrolyte abnormalities and telemetry for arrhythmia monitoring. Given the severity of the acute kidney injury, this patient was a poor candidate for observation dehydration care. In addition, the patient's condition was further complicated by an elevated troponin, decreased bicarbonate, and multiple electrolyte abnormalities. As such, this patient required close and complex care delivery that could not have been safely provided at a lower level of care.