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

Diagnosis: Acute Colitis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This case involves a patient with a past medical history of anxiety and hypertension who presented to the hospital complaining of nausea as well as vomiting and abdominal pain.  The submitted documentation indicated that the patient had recently undergone a surgical repair of a reversal of colostomy where she was found to have low potassium and has been treated with prior visits to the emergency department.  The patient was well-appearing on physical examination in no apparent distress.  There was no rebound and no guarding present.  There were multiple well-healed scars to the abdomen with a healing ostomy without signs of infection.  The recommendation was made for the patient to undergo a gastroenterology (GI) consult.  It was also recommended that the patient undergo laboratory and diagnostic studies.  The physician indicated the concern was that the patient may have colitis.  The physician indicated that the patient has not been able to eat, and with new complaints of fatigue and weakness it was recommended that the patient be admitted.  The patient's laboratory studies showed elevated white blood cell count of 20.  The patient also underwent additional laboratory studies revealing a positive Clostridium difficile infection.  The patient's computed tomography (CT) scan of the abdomen and pelvis revealed a suspicion of colitis.  It was recommended that the patient be treated with multiple medications that included intravenous (IV) Flagyl as well as ceftriaxone and vancomycin.  The patient was also given IV pain medication and fluids.  The patient continued treatment and continued to improve.  There were no further significant adverse events noted and given that this patient had improved and was able to tolerate oral intake, the patient was discharged. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient has multiple medical conditions, and was unable to tolerate oral intake and keep her food down. The patient was hypovolemic as evidenced by this patient's elevated creatinine of 1.4. The patient also had leukocytosis and a clinical suspicion of colitis. Given this patient's comorbidities and symptomatology as well as lab abnormalities, it was medically appropriate for this patient's care to be provided in an inpatient setting. 

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

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

Diagnosis: Abdominal pain.
Treatment: Inpatient Admission.

The insurer denied coverage for the Inpatient Admission.  The denial is overturned. 

This is a female patient who presented to the emergency room (ER) with complaints of abdominal pain, nausea, vomiting, and vaginal bleeding.  A pelvic ultrasound (US) revealed a single intrauterine gestation with a gestational age of 5 weeks and 1 day.  Magnetic resonance imaging (MRI) of the abdomen revealed findings that were equivocal for appendicitis. Since appendicitis could not be ruled out, the patient was presented with the following options:  Non-operative intervention consisting of antibiotic versus operative option.  

The patient elected for empiric treatment with antibiotics.  She was started on cefotetan 1 gram every 12 hours.  The plan was to treat her conservatively with intravenous (IV) antibiotics, serial abdominal exam, monitor labs and vital signs.  The patient progressed well.  Her nausea and vomiting resolved, her abdominal exam improved and her vital signs remained stable.  She decided that she preferred to leave against medical advice (AMA).

Acute appendicitis is the most common general surgical problem encountered during pregnancy.  The diagnosis is particularly challenging during pregnancy because of the relatively high prevalence of abdominal/gastrointestinal discomfort, anatomic changes related to the enlarged uterus, and the physiologic leukocytosis of pregnancy.  Appendiceal rupture occurs more frequently in pregnant women, especially in the third trimester, possibly because these challenges and reluctance to operate on pregnant women delay diagnosis and treatment.  Acute appendicitis should be strongly suspected in pregnant women with classic findings: abdominal pain that migrates to the right lower quadrant, right lower quadrant tenderness, nausea/vomiting, fever, and leukocytosis with left shift.  While the patient was afebrile, her presentation was suspicious for appendicitis.

Prompt diagnosis and surgical intervention are indicated, as delaying surgical intervention for more than 24 hours after symptom onset increases the risk of perforation, which occurs in 14 to 43 percent of such patients.  Maternal morbidity following appendectomy is comparable to that in non-pregnant women, except in patients in whom the appendix has perforated.  Importantly, the risk of fetal loss is increased when the appendix perforates.

Based on the above, and since appendicitis could not be ruled out, the admission was medically necessary to monitor the patient closely and interfere in case of worsening condition. 

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

The Inpatient Admission is considered medically necessary for this patient. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nerve treatment on bicuspid tooth. 
Treatment: Nerve treatment on bicuspid tooth, tooth 4 & tooth 5; white glass with high gold content crown. 

The insurer is denied coverage for nerve treatment on bicuspid tooth, tooth 4 & Tooth 5; white glass with high gold content crown. 

The denial is upheld. 

According to the documentation submitted, this patient is a female. A dental claim submitted for CPT codes D2750 (tooth #s 4 & 5), D3320 (tooth #s 4 & 5), D2954 (tooth # 4) and D2952 (tooth # 5) was submitted. Tooth #s 1, 2, 13, 18, 19, 20, 29 and 30 are noted as missing. 

Upon review of submitted documentation which includes 2 bitewing radiographs in addition to insurer correspondence it appears that this patient presented for dental treatment.  Multiple missing teeth were identified, and recommended treatment included root canal therapy in addition to full coverage crowns on teeth #4 and #5. The insurer has denied these services stating that there is insufficient documentation provided to determine medical necessity. The patient is appealing the decision. 

The only objective information provided for review is two bitewing radiographs. However, the radiographic images provided do not image the teeth in question on which the treatment is scheduled to be performed.  Documentation was requested but to date not received by IPRO. No other documentation is provided for review. There are no clinical images, dental treatment notes or other documentation available for review aside from the insurer correspondence. As there is inadequate documentation provided to support or justify the recommended treatment, these services are deemed not medically necessary. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the nerve treatment on bicuspid tooth, tooth 4 & Tooth 5; white glass with high gold content crown is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left-sided chest pain. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This male patient has a history of cardiac sarcoidosis, non-obstructive coronary artery disease, history of ventricular arrhythmias status post implantable cardioverter-defibrillator (ICD) implantation, heart failure with reduced ejection fraction, history of myocardial infarction, cerebral aneurysms status post clipping, and chronic kidney disease stage III.  The patient presented to the Emergency Room (ER) with complaints of chest pain, shortness of breath, and dizziness. The patient's electrocardiogram (EKG) showed occasional premature ventricular contractions (PVCs). The patient's troponin was initially and subsequently negative. The patient's physical examination demonstrated right lower extremity edema. The patient's computed tomography (CT) angiography was negative for pulmonary embolism. The patient's lower extremity ultrasound was negative for deep venous thrombosis (DVT).  The patient was admitted to the hospital.  The patient ruled out for myocardial infarction.  The patient was continued on antibiotic eye drops for recent eye surgery.  The patient was discharged home on after a period of medical stability. 

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. The patient presented with complaints of chest pain, shortness of breath, and dizziness.  The patient has a history of cardiac sarcoidosis and presence of an implantable cardioverter-defibrillator (ICD) for ventricular arrhythmias.  The patient's symptoms were concerning for a cardiac etiology.  The patient underwent appropriate initial evaluation in the Emergency Department (ED), which was unremarkable.  This included an unremarkable physical exam, a non-diagnostic electrocardiogram (EKG) and negative cardiac troponins. The patient's computed tomography (CT) angiography and lower extremity duplex ultrasonography were negative for pulmonary embolism and deep venous thrombosis, respectively.  There were no other high-risk symptoms present to suggest acute coronary syndrome.  As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance.  This patient's care could have been provided under the observational setting, allowing for additional diagnostic testing.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  Cardiac troponins remained negative.  For all of these reasons, the acute inpatient admission was not medically necessary for this patient. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission as not medically necessary.  

The denial is upheld. 

This female patient has a history and a diagnosis of osteoarthritis of the right knee. She had progressively worsening pain and function due to degenerative joint disease, refractory to non-operative treatment modalities and indicated for an elective right total knee arthroplasty. The patient was admitted for a right total knee arthroplasty. Post-operatively, the patient received pain management, antibiotics, intravenous fluids, deep vein thrombosis prophylaxis treatment, physical therapy and occupational therapy. The post-operative course was complicated by significant knee pain. Pain Management was consulted, and medications included oxycodone, morphine and Lyrica.  An x-ray and computed tomography of the right knee did not show any evidence of a fracture or loosening of the hardware. The patient also experienced low blood pressure readings of 90s/60s, and tachycardia in the 140s. The patient was on continuous cardiac telemetry monitoring which showed premature ventricular contractions. The patient's condition improved, and she benefitted from continued physical therapy and occupational therapy sessions. The patient was deemed hemodynamically stable for discharge with outpatient instructions regarding her procedure, wound management and medications for pain management.

The records show the patient underwent a non-complicated total knee replacement. Her post-surgical course was without problem. She was able to walk distances and bend her knee 90 degrees. 

There was no evidence of bleeding, infection nor inability to tolerate oral pain medications. She received pain medications with no requirement for continuous intravenous (IV) narcotic. 

There was a great discrepancy between Pain Management service and other treating practitioners. The report of intractable pain was not consistent. She was found to be comfortable with pain controlled as per Orthopedic service on several occasions. She was able to get out of bed and use a commode. She was able to walk 80 feet with rolling walker on the second post-operative day. Her vital signs were stable for the first two days after the procedure. She did not require treatment for her extensive underlying medical history. The treatment plan included discharge planning on the first and second post-operative day.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Migraine.
Treatment: Formulary exception for Ubrelvy (ubrogepant).

The insurer denied the Formulary exception for Ubrelvy (ubrogepant).  The denial is overturned.

The patient is a female with migraine headache disorder. She has tried and failed frovatriptan, sumatriptan and rizatriptan for abortive therapy. The attending physician (AP) is requesting Ubrelvy.

The Plan requires that the patient try and fail three preferred triptan medication for the acute treatment of migraine. This patient has tried and failed sumatriptan, rizatriptan and frovatriptan and therefore satisfies the criteria. Ubrelvy is a standard of care treatment option for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied: D2750 white glass with high gold content crown tooth # 7. 
The denial is upheld.

The patient is a male who presented to the office of his dental provider for evaluation and treatment of tooth #7. Included for review are previous letters of appeal and denial, full mouth radiographic images from an unknown date, one page of American Dental Association (ADA) claim forms, and health plan documents.
Previous denials for the requested service have been based on a lack of medical necessity as the amount of tooth structure missing due to decay or trauma was not significant enough to warrant a crown, and that the radiographic appearance does not show that the amount of tooth structure missing warrants a crown.
In question is the medical necessity of the planned treatment of D2750 white glass with high gold content crown.

The health plan's determination is upheld.

No, the requested health service/treatment of D2750 white glass high gold content crown for tooth #7 is not medically necessary.
As the documentation provided does not have any diagnosis of the tooth from the notes, no description of findings from the notes, and no radiographic evidence of decay or trauma that supports the desired therapy, there is not support for the medical necessity of the planned treatment and thus the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis 

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is overturned

The patient is a female with past medical history significant for asthma who presented to the emergency department with complaints of right upper extremity pain and swelling after bumping her elbow on fence a week before. Vitals on presentation included: temperature 98.6 Fahrenheit, blood pressure 139/87, pulse 84, respiratory rate 20, oxygen saturation 99% on room air. Laboratory results included the following: White blood count 9.3, hemoglobin 8.2, hematocrit 28.9, creatinine 0.69, glucose 94.

The patient was empirically started on intravenous antibiotics (vancomycin and Zosyn) for possible cellulitis of the right arm. Ultrasound of the arm showed soft tissue edema, but no discrete fluid collection. Infectious Diseases consulted and recommended adjustment in antibiotic coverage. Orthopedics consulted and performed an incision & drainage procedure under regional anesthesia. Cultures grew methicillin-susceptible staphylococcus aureus (MSSA). Infectious Diseases evaluated patient and recommended transition to oral antibiotics. The patient remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management. 
 
According to documentation, the patient presented with a worsening right arm infection despite a course of oral antibiotics prescribed by urgent care. The patient was afebrile, hemodynamically stable; laboratory results were notable for elevated inflammatory markers. The patient underwent an incision & drainage procedure by Orthopedics. Based on above findings including documented failure of outpatient management, hospital admission was medically necessary for administration of intravenous antibiotics and surgical intervention.   

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 hospital admission is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lumbar facet arthropathy, cervical facet arthropathy, spinal stenosis of the lumbar region with neurogenic claudication, and vertebrogenic pain
Treatment: Pre-service request for back surgery
The insurer denied coverage for pre-service request for back surgery
The denial is upheld

The patient is a male with a history of lumbar facet arthropathy, cervical facet arthropathy, spinal stenosis of the lumbar region with neurogenic claudication, and vertebrogenic pain. He had a telemedicine visit with the Pain Management specialist to discuss pain management options to treat lower back pain. Magnetic resonance imaging of the back performed years ago revealed that pain was coming from vertebrogenic changes at lumbar level L3 to L4 (third and fourth lumbar bone). He has undergone 10 years of conservative care with physical therapy a home exercise program (HEP), medications, and injections. There was minimal relief. Pain was rated at a level of 8 out of 10. The physician recommended increasing the dosage of Gabapentin to 600 milligrams three times a day as needed (PRN), continuing Aleve PRN, continuing an HEP, scheduling medial branch block and facet joint injections, and obtaining authorization for the Intracept procedure to the L3-L4 level under fluoroscopic guidance. 

The Intracept procedure is "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 neurosurgeons or spine surgeons. There are no National Organizations which provide guidelines or 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 this procedure is currently not supported by the literature. There were small numbers of people evaluated for a short duration. The procedure is not a mainstay nor is it currently 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. As such, at this time the Intracept procedure is not supported by the literature. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the pre-service request for back surgery is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, Headache

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves a female who presented to the Emergency Department with complaints of dizziness, blurry vision and right arm tingling lasting a few seconds. She developed a left-sided frontal headache with left eye pain and worsening vision. She also indicated she had trouble speaking. She stated her symptoms have improved with the exception of a residual headache. She denied a past medical history and on physical exam was noted to be alert and oriented to person, place, and time. The electrocardiogram showed a normal sinus rhythm and it was recommended she undergo additional laboratory and diagnostic studies. The documentation detailed the patient had a computed tomography scan of the head showing no acute intracranial pathology. The laboratory studies did not reveal any significant hemodynamic instability. The computed tomography angiography revealed an essentially unremarkable study. The documentation indicated the patient was admitted to telemetry and given aspirin. It was recommended she undergo neuro checks and be evaluated by neurology. The documentation detailed the following day the patient was evaluated by neurology and given the period of stability without additional events, it was recommended per neurology that the patient be discharged with instruction to follow-up. 

The patient presented with dizziness and blurry vision with a discrete, brief episode of numbness in the right arm, developing then left-sided frontal headache with difficulty with speech. She had a residual headache in the emergency department. Computed tomography was performed showing no acute findings or hemorrhage. The patient was seen by neurology who advocated anti-platelet therapy with aspirin. Computed tomography angiography was performed which was unremarkable. Diagnostic studies along with medical management and specialty consultation could have been performed in the emergency department and at an observation level of care. Therefore, the inpatient admission was not medically necessary. 

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

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