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

Diagnosis:  Cellulitis.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of bilateral lower extremity cellulitis. He had history of recurrent cellulitis. He was previously treated with vancomycin, doxycycline, Aquaphor, Kenalog and hydroxyzine. Vital signs demonstrated blood pressure 145/76, pulse 86, respiratory rate 17, temperature 36.2C and O2 (oxygen) saturation 98%. Physical exam showed no acute distress or altered mental status.

The inpatient hospital admission was not medically necessary. The patient in this case was admitted for bilateral lower extremity cellulitis but did not require urgent surgical intervention. He did not have sepsis or septic shock. There was no rapidly progressive infection or pain out of proportion to exam findings. He did not have toxic shock syndrome, necrotizing fasciitis, joint involvement, involvement of a vascular graft, pyomyositis, gas gangrene or compartment syndrome. He was noted to have mild cellulitis with chronic venous stasis changes. There was no hemodynamic instability.
Although the patient required services in the hospital setting the monitoring, diagnostic testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible familial aortopathy
Treatment: Gene Panel Testing (code: 81410)
The insurer denied: Gene Panel Testing (code: 81410)
The denial is upheld.

The patient is an elderly male was referred for Gene Panel Testing (code: 81410). He has a history of aortic valve disease with mixed aortic stenosis/aortic insufficiency (AS/AI) and aortopathy by a dilated ascending aorta and a family history of sudden cardiac death (SCD). His cardiologist referred him for genetic testing for possible familial aortopathy. The requested coverage for the service has been denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Gene Panel Testing (code: 81410) was not medically necessary.

The request is for coverage for Gene Panel Testing (code: 81410) for aortic dysfunction or dilation (for example (e.g.), Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial 
tortuosity syndrome); genomic sequence analysis panel includes sequencing of at least nine genes, including FBN1 (fibrillin 1), TGFBR1 (transforming growth factor-beta receptor type 1), 
TGFBR2 (transforming growth factor-beta receptor type 2), COL3A1 (collagen type III alpha 1 chain), MYH11 (Myosin-11), ACTA2 (actin alpha 2), SLC2A10 (Solute Carrier Family 2 
Member 10), SMAD3 (Mothers against decapentaplegic homolog 3 a), and MYLK (Myosin Light Chain Kinase).
However, in this patient's particular case, the patient already has established aortic valve disease with mixed aortic stenosis/aortic insufficiency and aortopathy as evidenced by a dilated ascending aorta identified on imaging. The information obtained by genetic testing is unlikely to alter his management. The currently adopted guidelines on the management of thoracic aortic disease and proposed genetic screening recommendations are based on expert opinion and small group studies only, rather than high-quality data and evidence of improved outcomes. Therefore, based on the submitted information and the current published peer-reviewed medical literature, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, diabetes, osteoporosis
Treatment: Personal Care Services (PCS) - 12 Hours a Day, 7 Days a Week, Totaling 84 Hours
The insurer denied: Personal Care Services (PCS) - 12 Hours a Day, 7 Days a Week, Totaling 84 Hours
The denial is upheld.

This is an elderly female patient that has medical conditions that include dementia, osteoporosis, hypertension, hyperlipidemia, obesity, and diabetes. She lives alone. Her daughter reports her dementia is getting worse. The denial of personal care services (PCS) - 12 hours a day, 7 days a week, totaling 84 hours is being appealed. The health plan approved 8 hours a day, 7 days a 
week, totaling 56 hours. Uniform Assessment System (UAS) evaluation completed 5 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, 
transportation, bathing, and toilet use; extensive assistance with personal hygiene, dressing, walking, locomotion, and toilet transfer; and limited assistance with bed mobility and eating. The 
patient ambulates with a cane and requires verbal cues. She has bowel and bladder incontinence. A letter from the Provider reports the patient has progressive dementia, unsteady gait, and a history of falls. She would benefit from an increase in home attendant hours.

The requested health service is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions as well as progressive dementia. The denial of personal care services (PCS) - 12 hours a day, 7 days a week, totaling 84 hours is being appealed. The health plan approved 8 hours a day, 7 days a week, totaling 56 hours. Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires assistance with all activities of daily living. The appeal statement reports the patient has progressive dementia, unsteady gait, and a history of falls. The patient's daughter reports the patient's dementia has gotten worse. The information provided indicates a change in the patient's cognitive status but does not support a significant change in functional needs. Personal care services are not indicated for safety supervision. The currently approved personal care services 56 hours per week is sufficient to meet the patient's needs for assistance with activities of daily living. The proposed increase in personal care services to 12 hours a day, 7 days a week, totaling 84 hours is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 1 Diabetes Mellitus
Treatment: Ozempic
The insurer denied Ozempic.
The determination is upheld.

This is a male patient diagnosed with type 1 diabetes mellitus (T1DM) with type 2 diabetes features. This request is for Ozempic. The patient has had diabetes. He has completed comprehensive diabetes education. As per a letter, he has T1DM, he has been taking Ozempic 2 milligrams (mg) with a healthy diet and exercise and successfully lost weight and now need less insulin. He has a family history of both T1DM and type 2 diabetes mellitus (T2DM).
He has T1DM with type 2 diabetes features including insulin resistance and obesity. He has a hemoglobin A1C of 7.2. He is on Humalog, Basaglar, Lyumjev and Ozempic.
He started on Dexcom and Omnipod. He was diagnosed with T1DM with positive islet antibody.
His A1C was 7.2 percent (%) and 7.6 %. At issue is the medical necessity of Ozempic.
The requested Ozempic is not medically necessary.
Ozempic is a glucagon-like peptide-1 receptor (GLP1R) agonist(1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes (2-7). There are no studies showing safety or efficacy of Ozempic in patients with type 1 diabetes.
The patient is diagnosed with type I diabetes. The FDA label specifically prohibits use of Ozempic in type I diabetes.
The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Inpatient weight loss surgery (procedure code 43775)
The insurer denied coverage for Inpatient weight loss surgery (procedure code 43775).
The denial is Upheld.

The patient was seen and a sleeve gastrectomy request for Body Mass Index (BMI) of 35 with comorbidities and numerous unsuccessful diet/weight loss attempts was made.  

The indications for revision of bariatric surgery are inadequate weight loss, weight regain, or complications. [1] The National Institutes of Health (NIH) has indicated that bariatric surgery is appropriate for all patients with a body mass index (BMI) greater than 40, or for patients with a BMI of 35 to 40 with associated comorbid conditions. Obesity-related comorbidities are conditions that are directly caused by obesity or contribute to the severity of the condition. Obesity-related conditions include cardiovascular problems, diabetes mellitus, obstructive sleep apnea, asthma, musculoskeletal conditions, and various reproductive conditions. [2, 3]

Per clinical documentation, the patient previously underwent a lap band placement 11 years prior with replacement five years later. The patient lost at least 100 pounds. An esophagogastroduodenoscopy (EGD) did not indicate any complications related to the lap band. Specifically, the report indicated that there was "no erosion of band, no obstruction, perforation, or bleeding." BMI was 34.1. There is no indication that the patient has not had an inadequate weight loss. There are also no indications that there are complications related to the band. The requested removal of the lap band and conversion to a sleeve gastrectomy is not medically necessary. As the procedure is not medically necessary, the inpatient admission is also not medically necessary.

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 weight loss surgery (procedure code 43775) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female with lupus. Her history includes lupus nephritis and nephrotic syndrome, hypertension, cardiomyopathy, and fibromyalgia. She was admitted to the hospital with headaches. The patient was noted to have elevated renal function and anemia. She received treatment with fluids and blood transfusion. Her headache was treated with Tylenol, and the patient was subsequently discharged with outpatient follow up.

The inpatient admission was not medically necessary.

The patient could have safely and effectively been managed at a lower level of care. Inpatient level of care was not medically necessary as MCG (Milliman Care Guidelines) criteria were not met. There was no documentation of altered mental status, severe headache that persists despite observation care, severe dehydration, increased intracranial pressure, cerebrospinal fluid leak, venous sinus thrombosis, medication overuse related, nor any severe neurologic findings.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Herpes zoster

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is upheld
 

The patient is an adult female with past medical history significant for hypertension, diabetes mellitus, rheumatoid arthritis, and glaucoma who presented to the emergency department with complaints of headaches and vesicular rash to left jaw.

Vitals on presentation included: Temperature 99.2 degrees F, Blood Pressure-113/57, Pulse-110, Respirations-18, oxygen (O2) saturation-99% on room air. Laboratory results included the following: White blood cells (WBC)-3.7, Hemoglobin (HGB)-12.5, Hematocrit (HCT)-39.4, creatinine-0.83, glucose-156.

Patient was started empirically on intravenous antivirals (acyclovir) for presumed herpes zoster or shingles. Infectious Diseases, Ear, Nose & Throat (ENT), and Dermatology provided consultations. She was also started on doxycycline. Viral swab confirmed varicella Deoxyribonucleic acid (DNA). Patient remained afebrile, hemodynamically stable and was discharged to continue course of oral valacyclovir. 

According to documentation, patient presented with left sided herpes zoster infection. Otherwise, patient was afebrile and hemodynamically stable with unremarkable laboratory results including normal WBC. Patient did not have any evidence for mucosal involvement and no bacterial superinfection. Moreover, patient was able to tolerate oral intake. Based on these findings, patient met criteria for observation level of care; did not meet criteria for acute hospital 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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of generalized anxiety disorder (GAD), cauda equina syndrome status/post (s/p) laminectomy, major depressive disorder (MDD), and multiple sclerosis (MS) who was admitted with complaints of (c/o) chest pain associated with nausea, vomiting, and diarrhea. Her vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for a negative troponin, white blood cell count (WBC) 15.9. Imaging studies, including a chest x-ray (CXR) showed no acute pathology, transthoracic echocardiogram (TTE) showed no cardiac abnormalities, an ultrasound (US) of the abdomen showed no acute pathology. An electrocardiogram (EKG) showed new diffuse T-wave inversions (TWIs) with dynamic changes on repeat EKG. The patient was diagnosed with viral gastroenteritis and treated with intravenous fluids (IVF), anti-emetics, antibiotics, and pain control. The patient was discharged on 8/8/2023 in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) chest pain associated with nausea, vomiting, and diarrhea. For the chest pain, the patient's HEART [history, electrocardiogram (EKG), age, risk factors, troponin] score was 3 (moderately suspicious, non-specific repolarization disturbance on EKG, less than (<) 45 years of age, and normal troponin), indicating that the patient had a low score, and not a high score. For the abdominal pain, the patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. Given that the patient had stable vital signs, no unstable co-morbidities, negative cardiac biomarkers, no new left bundle branch block (LBBB), and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Pain management
The insurer denied the Intracept Procedure
The health plan's determination is upheld. 

This is a female patient diagnosed with Lower Back Pain; Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. Records show that the patient was recommended to undergo the Intracept procedure.
It was noted the patient has a history of low back pain that began more than 3 years ago and has had multiple treatments including activity modification, heat, ice, home exercise, physical therapy, and epidural steroid injections. Medication has included meloxicam. Nothing has provided significant relief and pain is impacting activities of daily living. It was noted the patient had an magnetic resonance imaging (MRI) performed and the provider states that it demonstrated Modic type I changes at disc spaces L (lumbar)5 and S (sacral)1 and the provider believes that this is the source of the patient's chronic back pain.

The Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). While the MRI does show findings of degenerative endplate changes, there are also other findings likely responsible for the patient's pain including disc herniation/protrusion at L (lumbar)5 - S (sacral)1 that abuts the traversing right S1 nerve root in the lateral recess. This procedure remains experimental and investigational as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Pain management
The insurer denied the Intracept Procedure
The health plan's determination is upheld. 

The patient is a female with complaints of chronic low back pain which began more than 3 years ago. Prior treatments have included activity modification, injections, physical therapy, as well as heat and ice. Pain impacts activities of daily living. Nothing has provided significant relief of the pain. A magnetic resonance imaging (MRI) lumbar spine demonstrated Modic type I changes at disc spaces L (lumbar)5 and S (sacral)1.

The proposed Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insureds life threatening or disabling condition or disease. The patient has complaints of low back pain.
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Pain management
The insurer denied the Intracept Procedure
The health plan's determination is overturned. 

This is a female who has a long-standing history of chronic back pain. Her pain started after a slip and fall 3 years ago. She describes her pain as sharp and shooting with no radiating pain to the lower extremities. Her pain is worse with forward flexion, and decreased by lumbar extension. Her prior treatments include physical therapy (PT), pain medications and bilateral S (sacral)1 transforaminal injections. 

The Outpatient Intracept Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrated the sustained improvements in pain and function of this intervention for patients with vertebrogenic pain. This patient has symptoms consistent with vertebrogenic pain. She had failed extensive treatments including physical therapy (PT), pain medications and bilateral S1 transforaminal injections. Further interventions are indicated to improve her pain and function. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is likely to be more beneficial than other standard treatments for the insured's disabling condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Use Disorder
Treatment: Substance Abuse Inpatient Rehabilitation Level of Care
The insurer denied Substance Abuse Inpatient Rehabilitation Level of Care.
The determination is upheld.

The patient is an adult male who was admitted to inpatient rehabilitation substance use disorder treatment of stimulant (cocaine and methamphetamine) and cannabis (marijuana) use disorders. He had a history of multiple past substance use disorder treatment episodes with relapses. His substance use primarily involved cocaine and cannabis. 
He did have hypertension treated with losartan and was blind in his right eye, as well as malnutrition. The patient was medically cleared at the time of admission and his laboratory assessment was normal or unremarkable with a positive drug screen consistent with history. There was no co-occurring psychiatric disorder. The patient denied suicidal behavior or psychiatric hospitalization. He was not receiving mental health services.
The mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. There were no severe symptoms such as psychosis, perceptual disturbance, depression or mania, or cognitive impairment. He had a sleep disturbance with insomnia.
The inpatient level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions, and recovery groups with peer support. 
At issue is the medical necessity of Substance Abuse Inpatient Rehabilitation Level of Care.
The requested health service/treatment of Substance Abuse Inpatient Rehabilitation Level of Care was not medically necessary for this patient. The structure and intensity of services necessary for the rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that the inpatient level structure and 24-hour nursing monitoring is medically necessary for a successful outcome in this case. There were no biomedical, psychiatric, or general medical issues that warranted the requested inpatient level services.
The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment.
There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment. Thus, the requested services were not medically necessary for this patient.