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

Diagnosis: Persistent sinusitis.
Treatment: Sinus surgery.
The insurer denied the sinus surgery.
The denial is overturned.

The patient is a female with chronic sinusitis. Medical management has included oral antibiotics, nasal steroids, oral steroids and oral antihistamines. The patient had also been on allergy shots. The patient's nasal endoscopy demonstrated mucopurulence. 

Balloon sinuplasty is the topic of this review.
Yes, the proposed treatment was medically necessary.

The patient had chronic sinusitis as documented by facial pain and pressure and noted mucopurulence on exam.  She had been treated with adequate medical therapy. The requested procedure is considered standard of care and is clinically appropriate for medically refractive chronic sinusitis. The procedure was not done for the convenience of the patient or the provider.

Chronic rhinosinusitis is a clinical diagnosis with the most common symptoms being congestion, facial pain-pressure, hyposmia, and nasal discharge. These symptoms are relatively non-specific, thus diagnosing requires demonstrating of inflammation either via endoscopy or imaging. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Clinical Indicators (see reference) advocate for sinus surgery for chronic rhinosinusitis when the patient has "persistent symptoms and objective evidence of disease by endoscopic and/or CT (computed tomography) imaging that is refractory to maximal medical treatment." Maximal medical therapy is the first line treatment and it includes, but is not limited to antibiotics, nasal steroids, oral steroids anti-histamines, nasal lavage, and possible allergy assessment. The definition of maximal medical therapy is not widely accepted but most otolaryngologist would include but not limit to nasal saline rinses, oral antihistamines, nasal steroids, nasal anti-histamines, prolonged  antibiotics, and possible allergy evaluation. Often patients with chronic sinusitis with or without nasal polyposis need extended courses of antibiotics (up to three weeks or more).

Per the American Academy of Otolaryngology-Head and Neck Surgery, maximal medical therapy is defined as: Oral antibiotics of two to four weeks duration for patients with chronic rhinosinusitis (culture-directed if possible), systemic and/or topical steroids (at the discretion of the physician), saline irrigations (optional), topical and/or systemic decongestants (optional, if not contraindicated), treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy (at the discretion of the physician) (see AAO-HNS [American Academy of Otolaryngology-Head and Neck Surgery] sinus surgery indicators).

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient had chronic sinusitis refractory to medical management with noted mucopurulence on nasal endoscopy.  Balloon sinuplasty is the standard of care treatment for medically refractory chronic sinusitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease-Bacterial Infection/Necrotizing infection
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history significant for recurrent diabetic foot ulcerations and recurrent sepsis with poorly controlled diabetes with multiple hospital admissions. He also suffers from chronic pain, opioid use disorder, alcohol (ETOH) and heroin abuse, and tobacco use. He had recently undergone a right Transmetatarsal amputation (TMA) with continued multiple open chronic ulcerations of the right TMA.

The patient presented to the emergency room (ER) with necrotizing infection of the left foot with sepsis and required emergent left below knee amputation (BKA) guillotine open amputation with closure of the left BKA. His postoperative course was complicated by ETOH withdrawal and acute on chronic pain and acute blood loss anemia requiring 3 units of packed red blood cells (PRBCs) transfusion. The patient fell and traumatized the left BKA stump on with a computed tomography (CT) scan of the left BKA stump showing a large hematoma with dehiscence of an area of the BKA stump suture line with ulceration. The hematoma was treated nonoperatively with recommendations to closely follow the patient's hematocrit. The patient was treated with intravenous antibiotics which were completed. He was discharged to rehabilitation.

The requested Inpatient Stay is medically necessary.
The patient is a very complex patient with multiple comorbidities. The medical notes provided indicate that the patient has very poor insight into his diabetes and his condition with multiple hospitalizations for diabetic foot ulcerations and infections. His poor medical insight is reinforced by his waiting at home with infection of his left foot until it was so infected that he required an emergent guillotine left BKA open amputation. The patient is documented as poorly compliant with physical therapy and in fact fell to the ground banging the newly performed left BKA stump resulting in hematoma and suture line dehiscence and ulceration. The patient is not safe for discharge home. The 2019 study by Phair et al. (see references) showed that the overall 30-day readmission rate after BKA was very high at 29.4% with stump complications accounting for 35.8% of readmissions.
Given this, it was reasonable to keep the patient in the hospital until a suitable rehabilitation bed could be found when he was safely discharged to rehabilitation. The need for rehabilitation placement is reinforced by the 2014 study by Curran et al (see references) that showed that non-home discharges (OR, 0.7; 95% CI, 0.6-1.0) were protective of readmission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned.

This patient presented to the hospital complaining of chest pain radiating to his left arm. Symptoms were accompanied by headache and blurry vision. Past medical history was significant for hypertension and diabetes. Upon arrival to the hospital blood pressure was markedly elevated: 188/90mmHg (millimeters of mercury). Physical examination revealed no other abnormalities. 12 lead electrocardiogram revealed normal sinus rhythm, right bundle branch block and left anterior fascicular block. Serum blood testing revealed an elevated troponin level (0.14 ng (nanogram)/ml (milliters) and an elevated creatinine (1.7mg/dl (deciliter)). The patient was admitted to the hospital for treatment of hypertensive emergency and further testing. Echocardiography revealed asymmetric septal hypertrophy and a preserved LVEF (left ventricle ejection fraction) of 65% [percent]. Regadenason perfusion testing revealed no evidence of ischemia and an LVEF of 61%. Blood pressure (BP) was treated with hydralazine, carvedilol and amlodipine therapy. The patient's blood pressure still remained elevated ranging from 177-182/90. Ultimately BP was reduced to 144/72 and the patient was discharged. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. Hypertensive emergency is defined as BP> (greater than) 180/120 with target organ damage. (Reference 1) In this patient, serum troponin and creatinine levels were elevated consistent with cardiac and renal target organ damage. In addition, the patient noted lightheadedness and blurry vision. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Given this patient's failure to respond to initial medical therapy, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU (intensive care unit) for management of hypertensive emergencies (Reference 1). In conclusion inpatient admission was medically necessary for this patient.

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

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

Diagnosis: Pain in the left extremity, epigastric and
abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with past medical history (PMH) of seizures, prior stroke, deep vein thrombosis and pulmonary embolism who was admitted due to pain in the left extremity, worse in the lower than the upper extremity, as well as epigastric and abdominal pain. She was noted to be leukocytic and tachycardic. She did not respond to oral opiates requiring intravenous opiates. The hospital stay was denied by plan as it did not meet criteria for inpatient hospitalization.

Yes, the proposed treatment, inpatient hospital admission, was medically necessary.
The inpatient hospitalization was medically necessary. 

The patient had severe pain that was not responsive to oral medications requiring intravenous opiates which necessitated close monitoring that would not be possible in the outpatient setting. Furthermore, Milliman Care Guidelines indicate that inpatient admission is indicated when there is severe pain requiring parenteral treatment and close monitoring which occurred in this patient and therefore this admission meets inpatient admission guidelines.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The plan put the patient at risk for morbidity and mortality by denying the inpatient hospitalization stay as the treatment that she received could not be done in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This case involves a female with a history of endometriosis, Epstein-Barr infection, lupus, and a sleeve gastrectomy who presented to the emergency department complaining of abdominal pain, nausea, and vomiting.  Imaging studies indicated the patient was suffering from acute cholecystitis.  She was subsequently admitted where surgery was consulted.  She was treated with Zofran, tramadol, Reglan, and intravenous fluids.  She underwent a laparoscopic cholecystectomy and was cleared for discharge on 
with instructions for follow-up.  

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

According to the Milliman Care Guidelines, in order to meet the criteria for admission to inpatient care, the patient must have documented evidence of one more the following to include that there is hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs, identification of etiology or finding that requires inpatient care to include aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction), or that the patient requires evaluation with no eating or drinking for extended periods of time, if the patient has the inability to maintain oral hydration that persist after observation care, has suspected toxic megacolon, bacteremia, or needs to undergo procedure that cannot be performed on an ambulatory basis.  The information provided for the review noted that when the patient presented for evaluation in the emergency department, she had imaging evidence concerning for acute pathology in the right upper quadrant including acute cholecystitis.  Initial laboratory studies show an elevated white blood cell count of 13.29, elevated neutrophil at 9.5, and elevated monocyte at 1.2.  Subsequent abdominal ultrasound showed dependent echogenicity in the gallbladder compatible with sludge and likely small stones.  She had nonspecific gallbladder wall thickening, trace pericholecystic fluid versus gallbladder wall edema was subsequently given clindamycin 600 mg (milligrams) intravenously.  Showed questionable enteritis in the left hemiabdomen, and subsequently underwent the laparoscopic cholecystectomy.  Given that the patient had severe pain and had symptoms of peritoneal signs, it was determined that inpatient care was warranted.

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Treatment: 22899 Unlisted Procedure Spine (intracept),
C9752 Destruction of Intraosseous Basivertebral Nerve First Two Vertebral Bodies Including Imaging Guidance, Lumbar/Sacrum
The insurer denied the 22899 Unlisted Procedure Spine (intracept),
C9752 Destruction of Intraosseous Basivertebral Nerve First Two Vertebral Bodies Including Imaging Guidance, Lumbar/Sacrum
The denial is overturned

The patient is a female with chronic low back pain for whom an Intracept procedure has been requested. Coverage for the procedure was denied by the health plan as experimental/investigational.

The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, RFA (radiofrequency ablation), SI (sacroiliac) joint injections. She has failed laminectomy and medication management.  MRI (magnetic resonance imaging) shows Modic changes.   Physical exam does not reveal any neurological injury, or signs of radiculopathy.

Yes, the health plan should cover the Intracept procedure.
The requested Intracept procedure is medically appropriate. The patient has failed all conservative options. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, RFA (radiofrequency ablation), SI (sacroiliac) joint injections. She has failed laminectomy and medication management. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury, or signs of radiculopathy.

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 use in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.

Alternatives are more invasive. These include spinal fusion, which has not shown to have good results in axial low back pain without instability, especially in re-operation. Another alternative is SCS (spinal cord stimulator), which has not shown to have excellent results in low back pain without radiculopathy.

The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown effective in RCT (randomized controlled trial) with 5 year results. Given all conservative options have been exhausted in this patient's case, and the proposed procedure is less invasive and potentially has better results than the alternatives, it is medically appropriate.

Yes, the Intracept procedure is more beneficial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

This is a case of a woman that presented to the hospital complaining of chest pain and shortness of breath. The patient reported use of crack cocaine prior to presentation. Past medical history was significant for schizophrenia, diabetes mellitus and EtOH (ethanol alcohol) abuse. Upon arrival to the hospital vital signs were stable: blood pressure of 139/89mmHg (millimeters of mercury), pulse of 98 bpm (beats per minute). Physical examination revealed no abnormal findings. A 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with intermittent pre-excitation and ST (interval on EKG) segment depressions in the inferior and precordial leads. In addition, a prolonged QTc (interval on EKG) interval of 540 msec (milliseconds) was noted. Serum blood testing revealed an elevated troponin (0.04 ng/ml [nanogram per milliliter]) which normalized, an elevated CPK (creatinine phosphokinase) level (417 U/L [unit per liter]), and a reduced serum magnesium (1.5mg/dl [milligram per deciliter]). The patient was admitted to the hospital for observation and treatment. Echocardiography revealed a preserved left ventricular ejection fraction. Following treatment with nitrates and repletion of electrolytes, the patient's chest pain resolved and she was discharged. 

This patient presented with chest pain, an abnormal electrocardiogram, and positive cardiac enzymes. This patient presented with chest pain and dyspnea. Her pretest probability of coronary artery disease is intermediate (Reference 1). Utilizing the HEART (history, EKG, age, risk factors, and troponin) score she was considered high risk (Reference 2). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al (Reference 3). Using the HEART score risk stratification schema, this patient would have a high risk of major adverse cardiac events [myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Risk stratification utilizing the TIMI (thrombolysis in myocardial infarction) risk score also demonstrate that this patient was high risk for major adverse cardiac events (Reference 4). These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary. Given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate.

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

Diagnosis: Essential tremors, hypertension, anxiety, degenerative disorder, osteoarthritis and difficulty walking.
Treatment: Increase Personal Care Worker (PCW) Services to 7 Days per Week, 12 Hours per Day; 84 Hours per Week.
The insurer denied the Increase Personal Care Worker (PCW) Services to 7 Days per Week, 12 Hours per Day; 84 Hours per Week.
The denial is overturned.

The patient is a female with request for increase in personal care worker (PCW) services from 53 hours per week to seven days per week, 12 hours per day; 84 hours per week. 

The reason for prior denial was that plan criteria were not met.

Yes, the proposed increase in personal care worker services to seven days per week, 12 hours per day, 84 hours per week is medically necessary.
The proposed treatment is medically necessary. The patient has several comorbidities including essential tremors, hypertension, anxiety, degenerative disorder, osteoarthritis and difficulty walking. 

The patient is not able to perform her activities of daily living and is dependent on others. She has limited mobility. She needs reminders for her medications. The patient has been having worsening essential tremors and can not eat by herself anymore. She needs assistance with feeding. She is also at risk of falls.  The requested increase in services are appropriate and needed at this time.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient has worsening neurologic condition and needs more hours of help and supervision to ensure safety.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is the case of a female patient who had a history of previous hospitalizations for enteritis and presented with abdominal pain, nausea, vomiting, and diarrhea. There was a concern that she had Crohn's disease and she was on Budesonide. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A computed axial tomography (CAT) scan revealed pancolitis. Stool testing was done. There was a concern that she had inflammatory bowel disease (IBD) but the endoscopy and colonoscopy were negative. 

Clinical indications for admission for Gastroenteritis [Milliman Care Guideline (MCG) M-170] include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Inflammatory Bowel Disease (MCG M-565) include having severe ulcerative colitis as manifested by signs of hemodynamic instability, abscess, fistulizing Crohn's disease, toxic megacolon, intestinal perforation, intestinal obstruction, peritoneal signs, severe anemia, acute renal failure, and bacteremia. The patient did not have these conditions. 

This patient required a workup for the gastroenteritis and there was a concern that she had IBD. The colonoscopy was negative for IBD. She was stable to have had an outpatient colonoscopy. Intravenous (IV) hydration, stool testing, and antibiotics could have been given with observation status. She did not meet MGG criteria for admission for either Gastroenteritis or IBD. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.