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

Diagnosis: Shortness of Breath and Leg Swelling. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He presented with shortness of breath and leg swelling. He has a diagnosis of CHF (congestive heart failure), but he had been non-compliant with his medications and diet. 

The patient's exam showed hypertension and decompensated heart failure. He also had mild decrease in renal function. He was admitted to telemetry. He received treatments such as IV (intravenous) Lasix. He responded to interventions, improved, and signed out AMA (against medical advice). 

The denial and appeal is for appropriateness of inpatient level of care. 

No, the Inpatient admission was not medically necessary. 

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care that was provided was telemetry, which is frequently performed at a lower level of care status. The patient was admitted for monitoring and treatment of a non-compliant patient with a hemodynamically stable patient. Neither testing nor treatment required an inpatient level of care. There was no "complex" care required in this patient's care. While there was always a potential for an adverse event, one did not happen, and no actual added treatment was needed. 

Milliman criteria requirements for ACS (acute coronary syndrome) do not apply, as the patient did not meet criteria to support unstable angina, as the patient was pain-free. Enzymes were negative, and no ACS (acute coronary syndrome) therapy was recommended. EKG (electrocardiogram) showed no acute changes, and no acute medical treatment was given for ACS (acute coronary syndrome). All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to have been in a lower level of care status. Thus, inpatient level of care was not medically necessary. 

The denial was consistent with guidelines and usual community care. The patient's AMA (against medical advice) status did not affect the opinion. 

In the appeal letter, the use of Definity was included as a proposed justification for the patient's admission. It is this reviewer's understanding that Definity is an agent that is only used to enhance contrast on an echocardiogram, and that has no therapeutic value. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-low back pain.
Treatment: Surgical Services (All). 
The insurer denied INTRACEPT procedure. 
The denial is overturned.

This patient is a male who has persistent low back pain. His pain level is 7/10. He underwent transforaminal epidural injections targeted bilateral lumbar (L)4 and L5 levels, which alleviated his radicular pain. He continued to have persistent low back pain that failed radiofrequency ablation. The physical examination  revealed mild discomfort at the time of evaluation, lumbar spine range of motion was limited in flexion. A magnetic resonance imaging (MRI) scan was remarkable for discogenic endplate changes most pronounced at L4-5. This patient was recommended to have the INTRACEPT procedure for his persistent back pain.
At issue is whether the proposed health service or treatment INTRACEPT procedure is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.

The health plan's determination is overturned in whole.

The proposed health service or treatment INTRACEPT procedure is likely to be more beneficial than any standard treatment for the patient's condition.
This patient has persistent back pain. He had failed extensive treatments including radiofrequency ablations. He has signs and symptoms consistent with pain related Modic changes at L4-5 endplates. The INTRACEPT system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There is strong clinical evidence to show sustained clinical improvement in function and pain with an excellent safety profile of this intervention. The alternative is a L4-5 lumbar fusion, which carries more serious risks and complications with risks from general anesthesia and a long recovery time.
Therefore, the proposed health service or treatment INTRACEPT procedure is likely to be more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-low back pain .
Treatment: Surgical Services (All). 
The insurer denied INTRACEPT procedure. 
The denial is upheld. 

The patient is a male with a history of low back pain of unstated duration. Per the treating provider's note, he has been treated most recently with both bilateral transforaminal epidural steroid injections (TFESI) and bilateral lumbar medial branch radiofrequency neurotomy (MB RFN). While it is reported that the radicular pain was alleviated with TFESI it is stated that there is persistent axial low back pain. The plan is to repeat the same. In addition, the provider states a plan to pursue basivertebral nerve (BVN) ablation (Intracept) at lumbar (L)5 which he states exhibits "Modic II endplate changes at L5 inferior aspect." The radiologist's interpretation of the magnetic resonance imaging (MRI) scan of the lumbosacral spine states "There is degenerative disc disease with decreased thoracic (T)2 signal at L4-5 and L5-sacral (S)1 with degenerative endplate changes most pronounced at L4-5."
The issue at hand is whether the proposed health service of INTRACEPT procedure is likely to be more beneficial than any standard treatment for the patient's condition.

The health plan's determination is upheld in whole.

The proposed health service of INTRACEPT procedure is not likely to be more beneficial than any standard treatment for the patient's condition.
The criteria for proceeding to a BVN ablation based upon inclusion criteria in the clinical studies, requires that the individual have radiographically evident Modic I or II type endplate changes on a MRI. While the treating provider indicates that there are Modic II type endplate changes on the MRI, the radiologist's interpretation does not corroborate this finding. It is stated that there are "degenerative endplate changes at L4-5." This is a non-specific finding and could include findings not consistent with Modic type I or II changes. In the absence of Modic type I or II changes, a BVN ablation is not likely to be more beneficial than the standard treatment for the patient's condition.
Therefore, the proposed health service of INTRACEPT procedure is not likely to be more beneficial than any standard treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-low back pain.
Treatment: Surgical Services (All). 
The insurer denied INTRACEPT procedure. 
The denial is upheld. 

The patient is a male with complaints of low back pain. A magnetic resonance imaging (MRI) scan of the lumbar spine reported a stable exam, disc herniation at lumbar (L)5-sacral (S)1, degenerative changes at L4-5. The patient had undergone a radiofrequency ablation and has undergone lumbar epidural injections. The physical exam demonstrated straight leg raise was negative, with muscle strength 5 out of 5. The provider has recommended an INTRACEPT procedure.
At issue is whether the INTRACEPT procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The health plan's determination regarding the proposed health treatment is upheld in whole.

The INTRACEPT procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
The INTRACEPT procedure is designed for intraosseous basivertebral nerve ablation. Currently, this procedure is not supported by medical literature. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. Given this, standard treatments, such as physical therapy, home exercise program, cognitive behavioral therapy, have shown to be more beneficial than the requested procedure.
Therefore, the INTRACEPT procedure is not likely to be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This is a male patient with poorly controlled type I diabetes diagnosed four years previously. The patient presented to the pediatric endocrinology clinic with hypoglycemia. The blood sugar was 45. He is on Lantus 26 units and lispro using an insulin to carbohydrate ratio. The patient has had multiple episodes of hypoglycemia recorded by the school nurse in the last 30 days. The school nurse had reported glucoses between 38 and 66 in the morning. Upon arrival to the emergency room the glucose was 180. The patient was found to be COVID positive but was asymptomatic. His vital signs were stable.

No, the proposed inpatient admission was not medically necessary.
Admission to the hospital for hypoglycemia is needed if the patient has hypoglycemia that is treated in the emergency room and does not respond to treatment with dextrose, especially in the setting of long acting insulin or long acting medications like sulfonylureas.

This patient is on Lantus. The patient's glucose was 45 in the office. However the patient's glucose in the emergency department was 180. The patient was not unresponsive to treatment. The patient responded to treatment quite well. The patient's doses of insulin could have been reduced and the patient discharge from the emergency department without inpatient admission. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary. [1, [2, [3, [4, [5]

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient as the request is not medically necessary as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Diverticulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female who was admitted to an acute hospital setting. The patient had diverticulitis which had been diagnosed six days earlier. The patient had a computed tomography (CT) scan done at that time and was started on oral antibiotics. As the patient was symptomatic, she presented for evaluation. A repeat computed tomography (CT) scan did not show any significant change.  The patient had concurrent interstitial lung disease, leukocytosis, transaminitis and hypertension. The patient had a past medical history of anemia, kidney stone, depression, osteoporosis, pneumonia, and urinary tract infections.

No, the proposed inpatient hospital admission was not medically necessary.
The care that was provided was medically appropriate for the patients diagnosis; however, the level at which the care was provided was not medically necessary, as explained in detail below.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection of the large intestine called diverticulitis; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) 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 as provided could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is a child with a history of botulism, dysphonia, and obstructive sleep apnea (OSA). The patient presented for a sleep endoscopy with direct laryngoscopy, bronchoscopy, partial arytenoidectomy, right vocal cord injection, and epiglottoplasty. She was admitted for postoperative monitoring and was discharged the following day.

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

A pediatric patient with untreated sleep apnea and immediately postoperative from airway surgery would need inpatient monitoring overnight due to risk of airway edema/obstruction, which could happen quickly, leading to anoxic brain injury. Therefore, the inpatient hospital admission was medically necessary.

"Obstructive sleep apnea (OSA) is a common disorder of breathing but is probably underappreciated as a perioperative risk factor.

The patients with OSA have an elevated risk of perioperative complications. OSA is also an independent predictor of difficult airway management (19). Thus, intubation was difficult in 22-44% (percent) of patients with OSA, compared to 2-3% of patients without OSA; in 5% of cases, the attempt to intubate was unsuccessful. An analysis of medicolegal databases in the USA (United States of America) has shown that difficult airway management and respiratory arrest without respiratory monitoring in patients with presumed or confirmed OSA are the complications that most commonly lead to legal proceedings." (Fassbender, P., et al, 2016)

"Obstructive sleep apnea is a common childhood disorder which can lead to serious health problems if left untreated. Enlarged adenoid and tonsils are the commonest causes, and adenotonsillectomy is the recommended first line of treatment. Obstructive sleep apnea poses as an anesthetic challenge, and it is a well-known risk factor for perioperative adverse events. The presence and severity of an obstructive sleep apnea diagnosis will influence anesthesia, pain management, and level of monitoring in recovery period. Preoperative obstructive sleep apnea assessment is necessary, and anesthetists are ideally placed to do so." (Ohn, M., et al, 2020).
                                                 
The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: Inpatient admission 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She presented with three days of abdominal pain. She had one episode of vomiting and was found to have right lower quadrant tenderness. She had an abnormal urinalysis and was diagnosed with and treated for Urinary Tract Infection. She had a CT (computed tomography) scan revealing fluid around a thickened appendix. 

The patient underwent laparoscopic appendectomy. Post-operation, she recovered without complications and was discharged the day following surgery. 

No, the inpatient admission was not medically necessary. 

Inpatient admission is not indicated for an uncomplicated case of appendicitis. The patient could have been treated at a lower level of care. Given the patient's presentation and findings, treating the patient at a lower level of care would have been consistent with the standard of care in the surgical community. A lower level of care would not have compromised the patient's health, safety, or treatment provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cracked crown 
Treatment: Crown Porcelain/Ceramic (D2740) 
The insurer denied the Crown Porcelain/Ceramic (D2740). 
The denial is overturned. 

The patient is a female. Tooth # (number) 19 has a two-surface amalgam in it. 

Yes, the proposed treatment is medically necessary. 

The photo provided shows the recurrent decay around the existing failing amalgam filling. It also shows multiple cracks with decay around them in the tooth, as was described in the provider's letter. The tooth needs a crown to properly restore it.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Major depressive disorder, treatment refractory depression.
Treatment: Vagus Nerve Stimulation (Pre-Service).
The insurer denied the Vagus Nerve Stimulation (Pre-Service).
The denial is upheld.

The patient is a male who was recommended for vagus nerve stimulation for
treatment of depression. The patient has had depression for several decades. He
reportedly had greater than four different antidepressant trials from greater than two
different pharmacological classes. The patient also had treatment with
augmentation agents. The list that has been provided of various medication trials
lists the dose of treatment for less than half of the trials and does not list the
duration of treatment for any of the trials. The patient was stated to have
discontinued electroconvulsive therapy (ECT) treatment after four or five sessions
due to memory loss suffered. He reportedly had no response to treatment. He had
a history of one psychiatric hospitalization related to depressive illness. He received
36 treatments of transcranial magnetic stimulation (TMS) with no response starting
two and a half years ago. He stopped this treatment in the early fall of last year.

The information provided from various agencies within the federal government
establishes that the device was approved for coverage for individuals that were
enrolled in clinical trials. Additionally, the documentation indicates that the device is
restricted in use to individuals with appropriate training. A study that has been
provided as evidence of efficacy showed improvement in symptoms in the treated
group though no significant between treatment group difference. Another study
shows that the treatment significantly improved quality of life. An appeal letter sites
various American Psychiatric Association documents which indicate that vagal
nerve stimulation is effective. Another document from this organization indicates
that this treatment is recommended for those who are nonresponsive to other
treatments.

No, the health plan should not cover the proposed vagus nerve stimulation.

Medical necessity cannot be established based on the records provided. The
clinical documentation is not fully complete. The dosing and duration of the various
pharmacological trials is not adequately documented to confirm failed trials of
medications. Similarly, information regarding trials of treatments including
electroconvulsive treatment and transcranial magnetic stimulation is not fully
complete.

No, the requested vagus nerve stimulation cannot be established as more
beneficial than any standard treatment for the insured's condition or disease.
The clinical documentation is not fully complete. The dosing and duration of the
various pharmacological trials is not adequately documented to confirm failed trials
of medications. Similarly, information regarding trials of treatments including
electroconvulsive treatment and transcranial magnetic stimulation is not fully
complete.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stones
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male patient was admitted through the emergency room (ER)  with right renal colic.  Vitals revealed the following: temperature 36.2, pulse 78, and blood pressure 161/80.  The white blood cell (WBC) count was 10,100.  The creatinine was 1.12.  Computed tomography (CT) imaging demonstrated a seven millimeter (mm) right mid-ureteral calculus with hydronephrosis and a suspected left staghorn calculus.  The urinalysis has 50 white blood cells (WBCs).  The glucose was 247.  Intravenous (IV) pain medications, nausea medications, intravenous (IV) antibiotics and intravenous fluids (IVF) were administered.  

On day two, the patient was seen by Urology.  Intravenous (IV) pain medications, intravenous antibiotics and intravenous fluids were administered.   The white blood cell (WBC) count was 14,100.  The creatinine was 1.39.

On day three, the patient was treated with a right ureteroscopic stone laser lithotripsy and bilateral stent placement.

On day four, the patient was discharged home. He was afebrile and hemodynamically stable throughout the stay.

No, the proposed treatment was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, intravenous antibiotics and intravenous fluids followed by stent placement in a non-toxic patient can be provided at a lower level of care.

None of the Plan criteria were met. The following criteria for inpatient admission were utilized:
"Inpatient admission required[A] rather than observation care (see Renal Colic and Kidney Stones: Observation Care ISC guideline as appropriate) because of  one or more of the following(15)(16):
1)	 Hemodynamic instability
2)	 Acute renal failure
3)	 Severe pain requiring acute inpatient management
4)	 Urinary tract infection identified
5)	 Vomiting that is severe or persistent
6)	 Need for intravenous hydration support (inability to maintain oral hydration) despite outpatient and observation care treatment."

Renal Colic and Kidney Stones 
Admission is indicated for one or more of the following(1)(2)(3)(4)(5):
1) Hemodynamic instability
2) Acute renal failure
3) Bilateral obstruction
4) Single kidney with obstruction
5) Transplanted kidney with obstruction(9)(10)
6) Severe pain requiring acute inpatient management
7) Vomiting that is severe or persistent
8) Urinary tract infection (eg, pyelonephritis, obstruction)(11)
9) Need for intravenous hydration support despite observation care treatment
10) Stone removal procedure needed requiring inpatient admission (eg, postprocedural care needs require inpatient).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male. His history was significant for with polysubstance abuse and COPD (chronic obstructive pulmonary disease) with frequent exacerbation and history of intubations. He presented with worsening shortness of breath and wheezing.

The patient received multiple nebulizations in the ER (emergency room) and received steroids. The patient was admitted to acute in hospital level of care for the management of COPD (chronic obstructive pulmonary disease) exacerbation. The patient received oral prednisone as well as nebulizations during this admission. The patient also had hip pain and was awaiting MRI (magnetic resonance imaging).

The inpatient admission was denied by the health plan due to lack of medical necessity. This denial is being appealed.

No, the Inpatient admission was not medically necessary.
The patient had COPD (chronic obstructive pulmonary disease) exacerbation and had tried and failed home medications. The patient continued to have SOB (shortness of breath) and wheezing even after emergency room treatment. At the time of admission, the patient was hemodynamically stable and did not require supplemental oxygen. The patient was not using accessory muscles. Patient was able to speak in full sentences. The patient was able to tolerate oral medications. The requested admission was not medically necessary, as the patient could have been safely and effectively treated at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.