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

Diagnosis: Chronic Lower Back Pain

Treatment: nerve treatment in the spine

The insurer denied coverage for nerve treatment in the spine

The denial is upheld.

This patient has a history of chronic lower back pain. He presented to the Pain Management physician's office for a follow up visit for back pain. The patient has had pain for several years. Pain persisted despite physical therapy (PT), chiropractor treatments, a home exercise program, non-steroidal anti-inflammatory drugs (NSAID), Tylenol, and opioids. The pain interferes with his ability to stand and sit. Magnetic resonance imaging (MRI) of the lumbar spine revealed modic change type 1 and 2 at L[lumbar]5-S[sacral]1 as well as facet arthrosis and spondylosis. The physician recommended the Intracept procedure at L5-S1.  

Fischgrund and colleagues (1) published a double-blind, sham-controlled RCT [random control trial] evaluating the Intracept system and RF [radiofrequency] ablation of the Basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= (greater than or equal to) 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85Celcisus for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100 point scale) and a minimum VAS [visual analog scale] of 4 cm (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13% (percent)) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

In sum, The Intracept procedure is an experimental/ investigational procedure. The publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates.  UptoDate (3) has evaluated this procedure and concluded that it is still unproved.  There are other evidence-based interventions available to this patient.  

Based on the above, the medical necessity for the nerve treatment in the spine is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Platelet Count
Treatment: Inpatient admission
The insurer denied the inpatient admission
the denial is upheld.

The patient in this case is a woman. She was admitted to the hospital with thrombocytopenia.  She had been noted to have low blood counts and was being evaluated for this issue by a hematologist. She had outpatient labs done and was sent to the hospital by her hematologist due to very low blood counts, notably with a platelet count of 10. Hemoglobin was 7.3.

The patient had no symptoms, notably no bleeding or bruising. She was transfused one unit of platelets and admitted to the hospital. No further platelet transfusions were given during this hospitalization, and the patient remained hemodynamically stable during her hospital stay.  Neupogen was given, as her white blood cell count at the time of admission was 2.5 and ANC (absolute neutrophil count) was 1.6. There was no documented evidence of infection.  She was discharged.

No, the Inpatient admission was not medically necessary.
This patient had severe thrombocytopenia and required platelet transfusion, but had no bleeding or other symptoms.  She could have been managed with platelet transfusion alone without the need for acute care inpatient hospitalization.

Therefore, given the above, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD).
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 48 Hours/Week.
The insurer denied CDPAS: 48 hours/week.
The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, COPD (Chronic Obstructive Pulmonary Disease), anxiety, depression, oxygen dependence, osteoarthritis, and edema who had been assigned 21 hours/week of CDPAS (Consumer Directed Personal Assistance Services). There was a request to increase service hours and the patient underwent an assessment, assessing the patient at maximum assistance with tasks of ordinary housework and shopping while extensive assistance with tasks of meal preparation and stairs. With tasks of managing finances, managing medication, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body the patient was assessed at limited assistance while independent with tasks of walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. 

CDPAS: 48 hours/week is medically necessary for this patient.

There is documentation of progression of chronic medical problems including COPD, osteoarthritis, and rotator cuff injury. The assessment performed 6 months prior underestimated the patient's care needs at that time and patient's functional status has worsened since that assessment. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has no informal help and the insurer failed to document a plan to meet her ADLs and IADLs assistance needs when patient is alone. The patient's care needs cannot be met solely with adaptive equipment and medical supplies, as the insurer implied in the denial. The patient's primary care physician (PCP) documented medical necessity of increase in CDPAS services. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 48 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction 
Treatment: Inpatient Hospital Stay 
The insurer denied inpatient hospital stay. 
The denial is upheld.

The patient is a male with a history of alcoholism who was admitted to the hospital due to concerns about recent binge drinking and alcohol withdrawal. The last alcoholic beverage was 36 hours before the presentation when he consumed two bottles of rum. He experienced nausea and vomiting in the emergency department (ED). The patient denied any auditory or visual hallucinations or seizure activity-no prior history of delirium tremens or severe withdrawal symptoms. Upon admission, the Clinical Institute Withdrawal Assessment (CIWA) score is calculated at 7 due to tremors and nausea. He has had similar ED visits for alcohol intoxication with nausea and vomiting. 

The medical team continued the patient on CIWA protocol. He was given intravenous (IV) metronidazole and ciprofloxacin, for colitis, with a plan to de-escalate quickly given minimal symptoms. Later in the day, the patient was assessed by the attending physician, who felt the patient's pain is improved with famotidine, which makes gastritis the more likely cause of nausea and vomiting than colitis, as it was not consistent with the clinical picture.

The next day, the patient was reassessed and doing very well from an alcohol withdrawal standpoint, with CIWA scores of 0. His abdominal pain completely resolved, and he felt ready to go home. He was given options for outpatient alcohol rehabs. The medical team also prescribed 7 days of Cipro and Flagyl to complete colitis treatment. The question is whether the above presentation warranted an inpatient level of care.

The patient was admitted with mild alcohol withdrawal and mild colitis, both of which improved quickly. The patient was admitted due to concern for alcohol withdrawal symptoms and nonspecific radiographic findings of descending colon colitis. The admission history and physical states the patient's CIWA score is 7 and he was treated for CIWA protocol with diazepam, folic acid, and thiamine. The abdominal discomfort improved with Pepcid, and the abdominal exam was benign. Over the next 24 hours, with the initiation of antibiotics and appropriate treatment for alcohol withdrawal, the patient's symptoms completely resolved, and he was deemed stable for release from the hospital. Therefore, there is no clinical evidence that the patient failed observation care criteria. Alcohol withdrawal, when not severe, can be evaluated and managed under a lower level of care status. The patient, in this case, exhibited very mild alcohol withdrawal symptoms and no evidence of delirium tremens.

The patient has a completely benign abdominal exam from a colitis standpoint, and the computed tomography scan shows no evidence of abscess formation or perforation. There were no severe electrolyte derangements and no documented inability of the patient to tolerate oral medications. The vital signs stabilized after the initiation of IV fluids. Inpatient hospital stay is not medically necessary based on the severity of illness.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Pain Management Service 01 Unit (Intracept)
The insurer denied coverage for Pain Management Service 01 Unit (Intracept)
The denial is upheld 

This is the case of a female with a history of vertebrogenic low back pain. A magnetic imaging resonance (MRI) of the spine showed multilevel lumbar disc disease. At her appointment, the patient reported dull stabbing neck pain that radiated into her bilateral shoulders. She also reported low back pain that radiated to her left lateral thigh, posterior thigh, medial thigh, anterior thigh, calf, shin, medial foot, lateral foot, and toes. She rated her pain at an 8 on a scale of 1-10. She reported worsening pain and that her pain was exacerbated by standing and sitting. She tried and failed conservative therapies such as physical therapy, chiropractic therapy, home stretching, and anti-inflammatory medications. The Intracept procedure was recommended. 

The Intracept procedure is an "intraosseous ablation of the basivertebral nerve." It has been proposed to address low back pain identified by Mobic changes. The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeon nor spine surgeon. There are no National Organizations which provide guidelines nor indications.

A search was performed using PubMed. The key word was Intracept Lumbar. There were two references. The articles submitted by appeal were also reviewed. The findings were that this procedure is currently investigational/experimental. There were small numbers of people evaluated for a short duration. The procedure is currently being performed by an investigative group and likely IRB (Investigational Review Board). The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

The procedure is essentially a thermoablation performed within the vertebral body. 

There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer.

The requested service is not likely to be more beneficial than any of the standard treatment/procedure for this patient. 

The insurer's denial of Pain Management Service 01 Unit (Intracept) is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.

This is the case of a woman that presented to the hospital following a fall with injury to the face and left upper extremity. Past medical history was significant for hypertension and hypothyroidism. Her relatives noted that following the fall, she was confused as compared to her baseline (alert and oriented x [times] 3). Upon arrival to the hospital, she was complaining of left upper extremity pain. Vital signs were BP (blood pressure) 212/79 mmHg (millimeters of mercury) and pulse 70 bpm (beats per minute). Physical exam was significant for an abrasion of the face and knees as well as swelling and tenderness of the left upper extremity. X-ray revealed a fracture of the left humerus. Serum blood tests were significant for an elevated white blood cell count (19,000) and a markedly elevated thyroid stimulating hormone (94). The patient was admitted to the hospital for monitoring and treatment. She was evaluated and treated by an orthopedist. CT (computed tomography) of the head was without abnormality. Electrocardiogram and telemetry monitoring revealed normal sinus rhythm without ectopic beats. An endocrinology evaluation was performed for marked hypothyroidism. She was ultimately treated medically and discharged.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. This elderly patient fell and fractured her humerus while walking. She could not remember if she had tripped or lost consciousness. Initial evaluation revealed that the patient was confused, hypertensive, and markedly hypothyroid with a TSH (thyroid stimulating hormone) of 94. This patient falls into a high-risk group for syncope. According to AHA (American Heart Association)/ACC (American College of Cardiology)/HRS (Heart Rhythm Society) guidelines, it is reasonable to consider syncope as a cause of falls in elderly adults. (Reference 1) Moreover, these guidelines recommend a comprehensive work up in collaboration with an expert in geriatric care. In a study of individuals presenting to the emergency room, patients that were over the age of 70, presenting with minor trauma and no prodrome prior to falling or syncope were found to have high risk for cardiac events and required admission to the hospital for further evaluation and treatment. (Reference 2) Admission to the hospital for treatment was medically necessary in this case.

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

Diagnosis: Breast cancer

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

Admission was not medically necessary. The health plan acted reasonably. The patient had an uncomplicated mastectomy and reconstruction with tissue expander. According to the MCG (Milliman Care Guidelines), 25th Edition, Mastectomy, Complete with Insertion of Breast Prosthesis or Tissue Expander, Operative Status:

Ambulatory: Patients without need for prolonged (eg, more than 24 hours) postoperative observation or treatment (eg, for unstable comorbidities, bleeding tendency) 
Inpatient: Patients with comorbidities that adversely affect anesthesia or surgery, or that necessitate prolonged (eg, more than 24 hours) postoperative observation or treatment 

In this case, the records indicate the patient did not have any complications and did not require prolonged observation or treatment. According to MCG General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable and needed only routine postoperative care and analgesics. She could have been safely managed at an observation level of care.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial was overturned. 

This patient is a male with a history of chronic systolic heart failure due to unclear etiology, severe left ventricular (LV) systolic dysfunction, severe mitral regurgitation (MR), severe tricuspid regurgitation (TR), recurrent heart failure hospitalizations, crack-cocaine abuse, and medication non-adherence who presented to the emergency department (ED) with worsening shortness of breath and leg swelling for the past 1 week. He had recently been discharged from another hospital and has not taken his cardiac medication including Lasix for the past week. On presentation the patient was grossly volume overloaded on examination with labs notable for transaminitis and supratherapeutic international normalized ratio (INR) most likely due to congestive hepatopathy.
The patient was admitted to telemetry service under an inpatient level of care and started on aggressive intravenous (IV) diuresis. An echocardiogram was performed showing decline in his left ventricular ejection fraction (LVEF). The patient was subsequently transferred for further evaluation and treatment of decompensated heart failure with the plan for cardiac catheterization.
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Admission is medically necessary for this patient.
Evaluation and treatment of this patient for acute on chronic heart failure with gross volume overload associated with congestive hepatopathy was medically appropriate, necessary and in the best interest for the safety of this patient.  The patient presented with acute on chronic heart failure with gross volume overload and congestive hepatopathy consistent with severely decompensated heart failure. He required aggressive IV diuresis, 24-hour telemetry monitoring, and daily laboratory monitoring of end-organ function and electrolytes. The patient required transfer to another facility for appropriate higher level of care and further management with a cardiac catheterization to evaluate hemodynamics and rule out coronary artery disease (CAD). Given the severity of his decompensated state, the inpatient level of care is recommended by peer reviewed medical literature and expert consensus guideline statements on acute heart failure management. (1-3)
Therefore, the requested health service/treatment of Inpatient Admission is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with hydrocephalus status post ventriculoperitoneal (VP) shunt and seizures who is not on medications. The patient was admitted due to witnessed seizure. She was given intravenous fluids and levetiracetam. Despite this, the patient had another seizure. She was then admitted with plan of getting electroencephalogram (EEG), magnetic resonance image (MRI), neurologic monitoring every two hours, continuation of levetiracetam and lorazepam as needed.

Yes, the proposed inpatient admission was medically necessary.

The patient had another seizure which was not controlled despite administration of intravenous (IV) levetiracetam after the first witnessed seizure. This meets Milliman Care Guidelines (MCG) for inpatient admission. Furthermore, the patient needed close neurological monitoring every two hours which could not have been done as an outpatient or the hospital floor. Monitoring neurological signs every two hours requires intermediate care unit status or higher. Furthermore, given recurrent seizures and not being on medications for seizures (was having seizures every two weeks) puts the patient at high risk for status epilepticus.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The Plan denied inpatient admission despite the patient clearly meeting Milliman Care Guidelines (MCG) for inpatient hospitalization. Furthermore, patient was at high risk for status epilepticus and discharge without control of recurrent seizures is dangerous and not standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: E22. 1: Hyperprolactinemia D35. 2: Benign neoplasm: Pituitary gland. 
Treatment: Brain CT (computed tomography). 

The insurer denied the Brain CT (computed tomography). 
The denial is overturned. 

The patient is a male with a pituitary macroadenoma and hyperprolactinemia. The request is for head CT (computed tomography). 

Yes, the requested brain computed tomography is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

Imaging of pituitary lesions can be performed with either an MRI (magnetic resonance imaging) or CT (computed tomography). The patent has a treated pituitary macroadenoma. While MRI (magnetic resonance imaging) is the investigation of choice, CT (computed tomography) imaging can provide information that an MRI (magnetic resonance imaging) cannot, and is performed regularly to evaluate pituitary adenomas. The referring provider states that a CT (computed tomography) scan was recommended instead of an MRI (magnetic resonance imaging); therefore, there is a reason for this CT (computed tomography) to compare it to prior imaging.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus. 
Treatment: Humalog Cartridge 100Unit/ML (milliliters) SC (subcutaneous) SOCT (solution cartridge). 

The insurer denied the Humalog Cartridge 100Unit/ML (milliliters) SC (subcutaneous) SOCT (solution cartridge). 
The denial is overturned. 

The patient is a female diagnosed with T1DM (type 1 diabetes mellitus). This request is for Humalog cartridges. As reported; Humalog cartridges are used in the Inpen insulin delivery device. This pen works with phone application to calculate insulin doses based on time, carb ratio, target BG (blood glucose), correction factor. She is on Lantus 13 units daily; the ICR (insulin-to-carbohydrate ratio) was 1:12 and ISF (Insulin Sensitivity Factor) 1:75. She had a sample of Freestyle libre. 

The patient's recent A1C (glycated hemoglobin) was 12 %. 

Yes, the requested Humalog is medically necessary. 

There are no studies demonstrating superiority of one rapid acting insulin analog over another (1-4). The patient is using an Inpen insulin delivery device that only works with cartridges. The formulary alternative, Admelog, does not come in cartridge form. The request is consistent with generally accepted standards of medical practice. Therefore, the request is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, as the request is medically necessary as described above.