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

Diagnosis: Bilateral Foot Swelling

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient has a past medical history significant for rheumatoid and psoriatic arthritis who presented to the emergency room with complaints of bilateral foot swelling and purulent discharge.

Vitals on presentation included: temperature (T) max 102.0 F, blood pressure (BP) 132/68, pulse (P) 105, respiratory rate (RR) 18, oxygen (O2) saturation (sat) 97% (percent) on room air (RA). Laboratory results included the following: white blood count (WBC) 34.2, hemoglobin (HGB) 14.5, hematocrit (HCT) 41.0, creatinine 0.89, and glucose 116.

The patient was started empirically on intravenous antibiotics (vancomycin and cefepime) for bilateral foot cellulitis. The patient received wound care and pain medications. The patient improved clinically, remained afebrile, and hemodynamically stable. The patient was discharged to continue oral antibiotics (Cephalexin) as an outpatient.    

According to the documentation, the patient presented to the emergency department with abdominal pain and bilateral foot infection. The patient was febrile (102 degrees Fahrenheit), with tachycardia (heart rate-105). Laboratory results were notable for significantly elevated WBC (34.2) of unclear etiology. Based on the above findings in a high-risk patient on immunosuppressive therapy, hospital admission was medically necessary. 

Based on the above, the insurer's denial must be reversed. The health plan did not act reasonably with sound medical judgment.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary
inpatient hospital

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

This case involves a man with hypertension who was evaluated in the hospital for right inguinal pain and swelling for a week. The patient had associated redness in the overlying area but no other major associated symptoms, such as urinary frequency flank pain, fevers, or nausea. He was seen at an urgent care center and referred to the emergency department for further assessment. The temperature was normal at 97.6, heart rate 68, and blood pressure 135/86. Examination showed a well-appearing well-nourished man with a normal cardiopulmonary exam. The abdominal exam showed a soft nondistended abdomen with no tenderness or guarding. The bladder was nontender. The inguinal area showed a right-sided swelling and tenderness with a 6 centimeter (cm) induration area. There was no fluctuance present.

Based on the provided documentation, the inpatient hospital admission was not medically necessary. The patient had no major constitutional signs and symptoms, remained afebrile, and was hemodynamically stable throughout the hospital stay. Initiation of antibiotics produced an adequate and rapid response, and the patient was safely discharged from the hospital within 48 hours. There was no evidence of sepsis or septic shock. No major surgical interventions were performed that would qualify this stay, for inpatient care, based on the complexity of care. Interventional radiology biopsies were contemplated, which can be completed under a lower level of care or in the outpatient setting. The patient was able to handle secretions based on the left parotid mass and tolerate a diet. Beyond empiric antibiotic therapy and watchful waiting, no further interventions were deemed necessary, and the patient was discharged from the hospital within 48 hours of admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
Asked to review the case of a teenage female that presented to the hospital following an episode of syncope. Past medical history is significant for Postural Orthostatic Tachycardia Syndrome treated with midodrine and vocal tics/anxiety treated with Haldol and Lexapro.  She was seen one week earlier at the hospital following an episode of syncope and was released. On arrival to the hospital vital signs were stable (Blood Pressure 120/73, Pulse 68 ).  Physical examination was within normal limits.  She was admitted to the hospital telemetry unit for observation and treatment.  Sinus bradycardia was noted during overnight hours with heart rates in the 45-55 range.  Echocardiogram demonstrated normal biventricular function and no valvular abnormalities.  The patient continued to complain of lightheadedness despite normal blood pressure and heart rates.  Neurologic work up was performed including magnetic resonance imaging (MRI) of the brain and electroencephalogram (EEG). No abnormal findings were noted.  The patient was discharged with plans for a mobile telemetry monitor as well as outpatient follow up to assess for vertigo.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This patient presented with lightheadedness and recurrent syncope. She was treated for syncope and released several weeks prior to presentation.  Following midodrine treatment she had recurrent events.  According to the European Society of Cardiology, patients presenting with syncope must be risk stratified for future morbidity and mortality in order to determine the need for hospital admission. (Reference 1) In a study of individuals presenting to the emergency room, patients that were moderate or high risk for cardiac events had a poor prognosis and required admission to the hospital for additional testing and treatment. (Reference 2,3).  In this case, the patient was bradycardic and was also being treated with Haloperidol. She reported recurrent symptoms of lightheadedness while hospitalized and required additional neurologic work up and monitoring to ensure to rule out intracranial pathology or seizures.  The etiology of her syncope was not determined and she was discharged with follow up.  Admission to the hospital for treatment and risk stratification was medically necessary in this case in order to avert further syncopal episodes. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and Leg Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male. The patient had complaints of back and leg pain and was admitted to the hospital. The patient presented to the emergency department with new onset of numbness to the right foot. The patient was status post L3-S1 fusion revision 2 weeks prior and recently was diagnosed with a deep vein thrombosis (DVT). The patient had been placed on Xarelto. The patient had a history of dysuria for the past three days. The patient's initial exam showed no focal neurologic or muscular defects and full range of motion. The patient was started on intravenous Decadron, gabapentin, and antibiotics. There was no evidence of wound infection. The patient was evaluated on day #2 and was found to have improvement of left lower extremity weakness, numbness, and pain and dysuria had improved. The patient was recommended for physical therapy. The orthopedic evaluation indicated no surgical intervention was necessary. The patient was planned for discharge. The patient was discharged the following day. This is a review for the inpatient level of care for this admission.

The inpatient level of care was not medically necessary.

Inpatient level of care is indicated for complex medical conditions that require acute evaluation and intervention. This patient did not have significant findings on exam that would warrant immediate admission and evaluation. The patient had postoperative symptoms and were treated with medications. No acute intervention was necessary such as surgical intervention. Since the patient did not have any significant diagnoses that required extensive treatment and evaluation and did not have any complications from the surgical procedure, the need for the inpatient level of care is not considered appropriate. This treatment is not medically necessary since hospital admission would not be standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Intraosseous Basivertebral Nerve Ablation (code 64628)
The health plan denied Intraosseous Basivertebral Nerve Ablation (code 64628). The denial is upheld.

The patient is an adult male.

Per the appeals letter, the patient has a history of chronic back pain due to degenerative disc disease that resulted in Modic changes on MRI (magnetic resonance imaging). The patient had pain and failed treatment for greater than six months. Prior treatments include chiropractic care, medial branch block injections, transforaminal epidural steroid injections, heat, ice and over-the-counter medication. MRI (magnetic resonance imaging) demonstrated Modic type changes at the anterior aspect of T12.

Per a provided note, the patient presented with axial low back pain and previously had undergone a transforaminal epidural steroid injection and medial branch block with minimal improvement. The patient has tried methocarbamol with no relief, as well as seen chiropractic treatment.

Based on the documentation provided, and per current studies, the requested Intracept procedure is not recommended at this time. Although the patient has a history of chronic low back pain, MRI (magnetic resonance imaging) provided did not demonstrate any Modic type changes at the levels being requested. As such, the request is not recommended at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Intraosseous Basivertebral Nerve Ablation (code 64628)
The health plan denied Intraosseous Basivertebral Nerve Ablation (code 64628). The denial is upheld.

The patient is an adult male with low back pain for over ten years. Past treatments include non-diagnostic lumbar medical branch blocks at bilateral L4-S1, lumbar TFESI (Transforaminal Epidural Steroid Injection), chiropractor, heat, ice, ibuprofen, methocarbamol, and home exercise. MRI (magnetic resonance imaging) of the lumbar spine shows L2 Modic type 1, T12 Modic type II, L1 Schmorl's nodule, annular fissure, disc protrusion, facet arthropathy at L4-5, annular fissure and disc bulge at L3-4, and disc bulge and facet arthropathy at L2-3 as well as mild stenosis in the lower lumbar spine.

The request for Intracept procedure was denied coverage by the health plan, as there is not enough proof that it improves health, and it is therefore investigational. The denial is being appealed.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such, the health plan should not cover the requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Intraosseous Basivertebral Nerve Ablation (code 64628)
The health plan denied Intraosseous Basivertebral Nerve Ablation (code 64628). The denial is upheld.

The patient is an adult male with chronic low back pain for 10 years with recent worsening. He has had chiropractic care, heat/ice, medial branch block injections, and transforaminal epidural steroid injections. The patient has failed multiple medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. It has been shown effective in RCT (randomized controlled trials) with 5 year results.

However, the patient in this case is not documented to have failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, osteoarthritis and Parkinson's disease

Treatment: Personal Care Aide, 7 days x 12 hours x 2

The insurer denied coverage for Personal Care Aide, 7 days x 12 hours x 2

The denial is overturned


This is a very elderly female with multiple medical problems including hypertension, osteoarthritis and Parkinson's disease. She uses supplemental oxygen and is currently enrolled in a hospice program. She lives alone in a 2 bedroom apartment. The insurer approved personal care aide (PCA) services, 12 hours/day, 7 days/week and the request are for personal care aide (PCA) services 7 days per week, 24 hours per day (split shift).

The Uniform Assessment System (UAS) report dated and reviewed. The patient's cognition is described as independent. She is reportedly totally dependent for performing much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also reportedly requires maximal assistance for bed mobility, and she is essentially bedbound; without the ability to transfer or ambulate. Extensive assistance is reportedly needed for dressing. Limited assistance is reportedly needed for eating and personal hygiene. The patient is completely incontinent of bladder (Foley catheter) and frequently incontinent of bowel. The patient has bilateral lower extremity vascular wounds and heel pressure ulcers. The wound care is performed by the patient's daughter.

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the increasing personal care aide (PCA) services 7 days per week, 24 hours per day (split shift). She is bedbound with already existent pressure wounds along with complete incontinence which support additional personal care aide (PCA) services. 

From a physical medicine and rehabilitation perspective, personal care aide (PCA) services 7 days per week, 24 hours per day (split shift), is medically necessary.  

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 Personal Care Aide (PCA), 7 days x 12 hours x 2 Shifts services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED) complaining of a rapid heart rate and intermittent chest pain after hearing a gunshot behind his house. He reported consumption of a high caffeine beverage prior to his symptoms. He indicated that he had a history of anxiety. His medical history was otherwise negative. His physical exam was notable for tachycardia and was otherwise normal. An electrocardiogram showed sinus tachycardia without acute changes. His serum troponin, D dimer, brain (or B-type) natriuretic peptide (BNP) and thyroid stimulating hormone (TSH) levels were normal. A chest x-ray was normal. The patient was treated with intravenous fluid and lorazepam. His heart rate slowed to the 110s-120s. He was admitted to the hospital. An echocardiogram was performed and was normal. He remained in sinus tachycardia in the low 100s-120s. He was discharged on 3/18/23. At issue is the medical necessity of an inpatient admission.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with chest pain and sinus tachycardia. He had no cardiac risk factors, normal cardiac biomarkers and no ischemic electrocardiographic changes. He was hemodynamically stable and his risk for acute coronary syndrome (ACS) was very low. While he remained tachycardic, the rhythm was sinus and no potentially serious underlying cause, such as pulmonary embolism, acute hemorrhage or decompensated heart failure was identified. He did not require intensive monitoring or treatment with antiarrhythmic drugs. An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

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

The patient is a female admitted for lower abdominal pain that required morphine for relief. The patient has a history of (H/O) recurrent pancreatitis. The patient uses marijuana but denies ethyl alcohol (ETOH) use. Admission vitals were normal, and afebrile. On abdominal exam, there was generalized guarding without rebound. On labs, the white blood cell count (WBC) increased to 14.1. A computed tomography (CT) of the abdomen demonstrated a thickened colon - "diffuse non-specific colitis". The patient was given intravenous fluids (IVF), morphine as needed (PRN) and Cipro/Flagyl. 

The inpatient hospital admission is not medically necessary. The patient could have been safely and effectively managed at a lower level of care.  It's unclear what the final diagnosis is for the patient. The patient did not meet the clinical diagnosis of acute pancreatitis as indicated by the gastrointestinal (GI) specialist. The patient possibly had an acute infectious colitis. This was not complicated by perforation or megacolon. The patient improved very quickly while hospitalized and never appeared to be at risk for a serious complication (e.g. the need for surgery).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity

Treatment: Ozempic

The insurer denied coverage for Ozempic.

The denial is upheld. 

The patient has a diagnosis of obesity and a body mass index (BMI) of 42. The patient also has been diagnosed with polycystic ovaries, elevated lipids, and metabolic syndrome. The patient has been on weight watchers, an exercise plan, and diet modifications. The patient's physician is recommending that they start Ozempic. 

UpToDate has an article titled "Obesity in adults: Drug therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity. These medications should be used in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those individuals with a BMI of 30 or a BMI of 27 in patients with weight-related comorbidities. Semaglutide-Wegovy is a glucagon-like peptide-1 (GLP-1) receptor agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction as well as improvement in glycemia and lipids. 

This patient has obesity with comorbid conditions. The recommendation from UpToDate is that Semaglutide is beneficial for a patient with a BMI of 30 or above. There is no requirement that the patient also has to have diabetes. However, Ozempic has not been approved for obesity and is thus not medically necessary. The denial is upheld.

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 Ozempic is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia
Treatment: Xeljanz 10mg (milligram) tablets
The health plan denied: Xeljanz 10mg (milligram) tablets
The determination is: Upheld 

The patient is a male with severe alopecia areata affecting the entire scalp and body who has previously failed therapy with topical, intralesional, and oral systemic corticosteroids. The patient is currently on therapy with Xeljanz 10 milligrams (mg) twice daily with significant regrowth of hair on the scalp and body.

Xeljanz 10mg Tablets is not likely to be more beneficial than other standard treatment for the insured's life threatening or disabling condition or disease.

Xeljanz is an oral JAK (janus kinase) inhibitor that is not Food and Drug Administration (FDA) approved for the treatment of alopecia areata. While there are several case reports and case series showing some efficacy with Xeljanz in the treatment of this disease, there are no large multicenter randomized placebo-controlled trials evaluating the safety and efficacy of Xeljanz in the treatment of alopecia areata. Review of the current standard of care for alopecia areata and the current peer-reviewed medical literature show two oral JAK inhibitors, Olumiant and Litfulo, which are FDA-approved for the treatment of alopecia areata; these two other oral JAK inhibitors can be used by this patient with severe alopecia areata. There is no evidence in the medical literature supporting the superiority of Xeljanz over Olumiant or Litfulo in the treatment of alopecia areata. For these reasons above, the proposed treatment, Xeljanz 10mg tablets, is not likely to be more beneficial than other standard treatments for the insured's disease and therefore is not considered appropriate or necessary at this time.