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

Diagnosis: Asthma
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a male with asthma who presented to the emergency department (ED) with shortness of breath and nasal congestion times 1 day. An Albuterol nebulizer had been given at home with little effect. The review of symptoms (ROS) was negative for fever, rash, vomiting, diarrhea, or cough.
The ED vitals were, temperature 37.7, heart rate (HR) 148, respiratory rate (RR) 24, blood pressure (BP) 132/74 and his peripheral capillary oxygen saturation (SpO2) was 98 percent (%) on room air. The examination noted tachypnea (30's) with decreased air movement and wheezing with mild flaring. The patient was treated with Decadron and DuoNeb times 3 for acute asthma exacerbation. Respiratory swab was negative for Influenza, respiratory syncytial virus (RSV) and Coronavirus (COVID).
The chest x-ray showed a right middle lobe (RML) infiltrate so Cefepime was also given. The patient remained tachypneic despite interventions so was also given intravenous (IV) Magnesium Sulfate and he was admitted to the inpatient unit on every three hour Albuterol for further care.

The inpatient admission was medically necessary for this patient. This patient with known asthma presented with asthma exacerbation and was also found to have community acquired pneumonia. He was treated appropriately in the ED for an acute asthma flare yet symptoms persisted despite adequate time for treatment. Given persistent symptoms and tachypnea, the patient required inpatient admission for continued close monitoring and treatment.
According to professional guidelines, pediatric asthma flares are based on signs and symptoms with disposition apparent within 2-4 hours of initiation of treatment. This patient remained with tachypnea and wheezing and increased respiratory effort, requiring an escalation of care while in the ED. Thus, his case required inpatient level of care.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Durable Medical Equipment (DME) (including Wearable Defibrillators)

Diagnosis: Chronic Obstructive Lung Disease/COPD
Treatment: High-frequency chest wall oscillatory (HFCWO)

The health plan denied: High-frequency chest wall oscillatory (HFCWO)
The determination is: Upheld

The patient is a female with a medical history of right middle lobe, right upper lobe, and lingula focal bronchiectasis with a chronic cough and mucus production. Per the medical information provided, she has tried manual chest physiotherapy for airway clearance. The attending physician is requesting a high frequency chest wall oscillation system (HFCWO) for airway clearance.
At issue is the medical necessity of the HFCWO.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Durable Medical Equipment - High-frequency chest wall oscillatory (HFCWO) is not medically necessary for this patient.
This device works via delivery of an intermittent flow of air into a jacket, which rapidly compresses and releases the chest wall at a variety of frequencies. The oscillation in airflow within the airways has been shown to augment central and peripheral mucus clearance. Most available HFCWO systems are Food and Drug Administration (FDA) approved for airway clearance to improve bronchial drainage. The prescriber is requesting the HFCWO for a patient with focal bronchiectasis in the right middle lobe, right upper lobe, and lingula.
HFCWO has been shown to be effective in patients with cystic fibrosis (CF). However, therapies shown to be effective in CF are often provided to patients with diffuse bronchiectasis without definitive evidence of benefit. The goals of bronchiectasis treatments are to reduce the number of exacerbations and infections and to improve patient quality of life by reducing airway inflammation and mobilizing secretions. In recent years, there has been increased interest in validating therapies for patients with bronchiectasis from cystic fibrosis. Most recently HFCWO was evaluated for non-cystic fibrosis diffuse bronchiectasis, and it was found that HFCWO provides an improvement both in pulmonary function and quality of life related parameters in patients with bronchiectasis with increased secretions. However, studies are needed to establish the effectiveness of the different airway clearance devices and techniques for long-term home use. In addition, the patient does not have a documented failure of standard treatments to adequately mobilize retained secretions (for example, Acapella valve, positive expiratory pressure [PEP] valve). Therefore, without a diagnosis of diffuse bronchiectasis and trying, failing, or having a contraindication to alternative clearance therapies, the requested health service/treatment of Durable Medical Equipment - High-frequency chest wall oscillatory (HFCWO) is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult male with a past medical history of anxiety. He presented with diffuse abdominal pain. The patient was found to have a temperature of 101.6. His pulse rate was 120, and oxygen saturation was 88 percent (%) on room air. The transaminases were elevated as follows: aspartate aminotransferase (AST) 143, alanine aminotransferase (ALT) 99. Computed tomography (CT) scan of the abdomen / pelvis showed moderate colonic stool burden, distended gallbladder, and common bile duct dilation. He was treated with intravenous (IV) antibiotics and fluids. He was evaluated by surgery and 
gastroenterology. On day number (#) 2, the patient continued with intravenous (IV) antibiotics and bowel regimen. Supplemental oxygen was weaned to room air as tolerated. Diet was advanced to full liquids. On day #3, diet was advanced to a regular diet. 

The Inpatient admission was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. A lower level of stay would have been more appropriate for this patient. A lower level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


According to the documentation submitted, this is an adult male with no previous medical history who presented to the emergency department (ED) complaining of 1 day of right lower quadrant (RLQ) pain. He was afebrile with stable vital signs. As per the emergency room (ED) provider note the patient developed mid epigastric pain 2 days prior which migrated to the right lower quadrant (RLQ). He denied nausea or vomiting. Examination revealed right lower quadrant (RLQ) tender to palpation with no guarding or rebound. The patient was admitted. White blood cell (WBC) count was 14.51. Computerized tomography (CT) was consistent with acute appendicitis. He was scheduled for appendectomy.

The patient underwent an uneventful laparoscopic appendectomy.

Progress notes indicated the patient was doing well following surgery. He was tolerating diet. He was discharged with outpatient follow up.

Based upon the records provided the patient not require an acute inpatient admission but rather observation status as he did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful and there was no perforation. There was no evidence of a complicated post operative course requiring hospitalization and the patient was discharged within 23 hours. 

According to Milliman Care Guidelines (MCG)  Health Inpatient and Surgical Care 27th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; procedure completed; no evidence of post op or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet. Based upon the records provided, the patient reached these milestones, and should have been discharged following observation within a 23-hour observation period following surgery. In addition, the operative status criteria is ambulatory.   Given this the patient did not require admission but ambulatory status with observation. Furthermore, MCG also notes that extended stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) can be seen. Thus observation/ ambulatory status is justified in this case and not an acute inpatient admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: facial swelling

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an infant female patient who was evaluated in the emergency room with facial swelling. The swelling was to the lower left jaw and was hard and indurated. The patient had an increased white blood cell count and was febrile. The patient was started on antibiotics, antipyretics and intravenous (IV) fluids. 

Due to the age of the patient, elevated white blood cell count, and febrile status, this patient was properly admitted as an inpatient. The potential for a severe maxillofacial infection was present and could result in airway loss.

Per Ritwik, P., Fallahi, S., & Yu, Q. (2020), "Sixty-four records were included for analysis with mean age of 8.19  4.5 years. Significantly more patients received clindamycin (79.7%) than penicillin-based antibiotic (18.8%) with P < .0001. Forty-four (68.8%) children were admitted to the hospital and received parenteral clindamycin. The average hospital stay was 2.5  1.2 days, and average days till dental treatment was 5.2  8.9 days. Children who received intravenous antibiotic or had a primary tooth involved received dental treatment sooner, with P = .0036 and P = .03, respectively. Oral antibiotics were prescribed for children who were discharged from the emergency department. Children who received intravenous antibiotics or had an infected primary tooth received early definitive treatment."

Per Hoerter, J. E., & Malkin, B. D. (2023),"Odontogenic and orofacial infections are rare but important sequelae of dental infections. Dental care and the evaluation, treatment, and follow-up of these sequelae affect providers of many medical disciplines. Treating these infections in the early stages can be simple and confer minimal morbidity. However, delay in treatment can allow these infections to require many treatments by an interdisciplinary team and lead to permanent disability or death."

Per Abdul Satar, H., et al., (2021), "Paediatric orbital cellulitis is a potential sight- and life-threatening condition. It is a serious infection in children that can result in significant complications, including blindness, cavernous sinus thrombosis, cerebral venous sinus thrombosis, meningitis, subdural empyema, and brain abscess. Of the patients with orbital cellulitis, 17% died from meningitis, and 20% of the survivors had permanent loss of vision. Therefore, the potential for sight- and life-threatening complications makes prompt diagnosis and early treatment very important."                                                         

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is an adult recently postpartum female who presented to the hospital with abdominal pain, nausea, and vomiting of several days' duration. Vital signs were normal. She was tender in the right upper abdomen. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated at 92 and 126 respectively and total bilirubin was elevated. Ultrasound showed findings of gallstones; biliary ductal dilatation was not identified (common duct 4 millimeters). The patient was initially admitted to the hospital with the diagnosis of 
cholecystitis. She was treated with intravenous fluid, nothing by mouth status, pain medications, and serial examination and lab assessment. A hepatobiliary iminodiacetic acid (HIDA) scan on 
day #2 showed no uptake of contrast into the gallbladder consistent with cystic duct obstruction and acute cholecystitis. On day #2, the liver enzymes and bilirubin had further increased. On day #3, the patient underwent laparoscopic cholecystectomy with cholangiogram. Operative findings included common bile duct stones. Based on this intraoperative finding, gastroenterology was consulted for consideration of endoscopic 
retrograde cholangiopancreatography (ERCP). Endoscopic retrograde cholangiopancreatography was performed on day #4 with sphincterotomy and stone extraction from the common bile duct (CBD). The post-endoscopy course was uncomplicated, and the patient was able to be discharged from the hospital on the first post-procedure day. The health plan denial letter references the UnitedHealthcare Observation Services Guidelines. This letter does not acknowledge the additional diagnosis of 
choledocholithiasis or the implications of this diagnosis and need for additional intervention.

The proposed treatment was medically necessary.

The patient initially presented to the hospital and was admitted with abdominal pain and biochemical findings of biliary obstruction. She was appropriately and promptly managed with nothing by mouth status, pain management, and antiemetics. She was promptly imaged with ultrasound that did confirm gallstones and with a hepatobiliary iminodiacetic acid (HIDA) scan that confirmed cystic duct obstruction. Lab data initially showed elevated liver enzymes and bilirubin, although imaging did not identify biliary ductal dilatation. Follow-up labs revealed further elevation of the liver enzymes and bilirubin consistent with 
common bile duct obstruction. The patient underwent laparoscopic cholecystectomy with cholangiogram that identified common bile duct stones. Consequently, with the additional diagnosis of choledocholithiasis, the gastroenterology service was consulted, and the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction from the common duct. She did demonstrate clinical improvement following this intervention such that she was suitable for discharge from the hospital on day #5.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gait instability
Treatment: Inpatient Services
The insurer denied: Inpatient Services
The denial is upheld.

This patient is a school aged male who was admitted due to gait instability. In addition, the patient had bilateral lower extremity swelling, particularly in his left ankle, a maculopapular rash, foot drop, and purpura. His vital signs were normal. The patient's labs showed an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). X-rays were normal. The patient was started on intravenous fluids and was admitted. Upon admission, a magnetic resonance image (MRI) was performed. Neurology, Infectious Diseases (ID), and Rheumatology were consulted. The patient's clinical status improved, and he was discharged home the next day with no specific diagnosis.

The proposed treatment was not medically necessary.

The patient was admitted for leg swelling. He did not have signs of hemodynamic instability, focal neurologic deficits, sepsis, organ failure, failure of outpatient antibiotic therapy, or any other condition that required an acute inpatient level of care. The patient had normal vital signs and was tolerating oral intake upon admission. He did not require intensive monitoring, respiratory support, intravenous medications of fluids, frequent laboratory monitoring, frequent changes to his treatment plan, or any other service which necessitated an acute inpatient level of care. The patient's care, which included monitoring and specialty consultation, could have been safely provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation. 
The insurer denied: Intraosseous Basivertebral Nerve Ablation. 
The denial is upheld. 

The patient is an adult male with chronic low back pain. He has tried and failed chiropractic care, heat/ice, injections, medial branch block injections, medication management, physical therapy, radiofrequency ablations, and transforaminal epidural steroid injections. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. 

The health plan should not cover the requested health service. 

The requested health service or procedure is not likely to be more beneficial than standard treatments. 
The patient is an adult male with chronic low back pain. He has tried and failed chiropractic care, heat/ice, injections, medial branch block injections, medication management, physical therapy, radiofrequency ablations, and transforaminal epidural steroid injections. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. The Intracept procedure (intraosseous basivertebral 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 has been shown effective in RCT (randomized controlled trials) with 5-year results. 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. However, the patient in this case has not 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, and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation. 
The insurer denied: Intraosseous Basivertebral Nerve Ablation. 
The denial is upheld. 

The patient is an adult male with longstanding back pain. The patient failed MBB (medial branch block), medications, PT (physical therapy), RFA (radiofrequency ablation), and ESI 
(epidural steroid injection). MRI (magnetic resonance imaging) shows lumbar four to sacral one (L4-S1) Modic changes. The patient was recommended the Intracept procedure to these levels. 

The requested health service is not more beneficial. 

The Intracept procedure does not have an adequate history of non-industry funded studies that demonstrate long-term benefits. While there are large studies within the literature, these are all industry funded and there is a lack of understanding from within the community of spine surgeons regarding the science and long-term outcomes associated with this procedure. For this reason, the Intracept procedure is still considered experimental/investigational within the spine community and would not be considered medically appropriate for this patient. The patient should continue gold standard conservative therapy options, which include PT (physical therapy), injections, pain management, acupuncture, and chiropractic care amongst others. 
Per Micheli, et al, "BVN [Basivertebral Nerve] radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP [chronic low back pain] and evidence of Modic change types 1 and 2 in the L3 to S1 VEPs [vertebral body endplates] who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results." 
In addition, these studies have not been evaluated for long-term effective control that is equal or better than current best practices. 
Per Fischgrund, et al, "Patients treated with RF [radiofrequency] ablation of the BVN [Basivertebral Nerve] for CLBP [chronic low back pain] exhibited significantly greater improvement in ODI [Oswestry Disability Index] at 3 months and a higher responder rate than sham treated controls." 
Per Tieppo Francio, et al, "Treatment options for chronic axial LBP [low back pain] from damaged vertebral endplates start with conservative care, similar to other treatment algorithms, such as oral analgesics, opioids, and therapeutic exercises. However, conservative methods tend to be ineffective, and the identification and diagnosis with history and physical exam of this subset of patients with pathoanatomical vertebral endplate damage on diagnostic imaging are crucial to optimize outcomes and offer an effective treatment option, such as the BVN [basivertebral nerve] ablation."