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

Diagnosis: Leg Ulcers. 
Treatment: Ambulatory Surgery (code 37238 x 1). 

The insurer denied the Ambulatory Surgery (code 37238 x 1). 
The denial is upheld. 

The patient is a male. He presents with bilateral leg swelling and leg tiredness. He also has recurrent left ankle venous ulceration. He has previously undergone bilateral axial saphenous ablation and bilateral iliac vein stenting. He has used compression stockings for more than three years. His current symptoms substantially affect daily activities. The provider has recommended bilateral iliocaval venogram with intravascular ultrasound with possible angioplasty or repeat stenting of the iliac veins. Coverage was denied because there is no imaging study showing a blockage. 

No, the requested code 37238 is not medically necessary. 

This patient has severe venous insufficiency. It is reasonable for the provider to suspect recurrent stenosis of the patient's iliocaval system, considering that she has undergone previous intervention. However, before proceeding with an invasive procedure as proposed, it is important to first perform, if available, a noninvasive imaging study of the iliocaval system. The only available study is the lower extremity venous duplex, which makes no mention of the iliocaval segment. The duplex could be repeated with a request to examine the iliocaval segment. If the segment in question cannot be seen on duplex, other non-invasive studies can be obtained, such as a CT (computed tomography) venogram. No such testing has been done in this case. 

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: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a male who presented to the emergency department (ED) with right knee pain, worrisome for cellulitis. The symptoms were present in the outpatient setting, and the patient was assessed by an orthopedic surgeon three days before admission and treated with amoxicillin. The right knee range of motion was intact, but there was a concern about the spread of the erythema. 

The ED documented low suspicion for septic arthritis. The patient received intravenous (IV) Unasyn, and laboratory studies were requested. The ED requested admission to the hospital, and the medicine service saw the patient. The medical team reports the right knee with tender erythematous skin and soft tissue swelling in the anterior knee, with a small dry scab below the right knee appearing to be a small skin breakdown. The medical team documented a principal diagnosis of rapidly progressing lower extremity cellulitis and failed trial of oral antibiotic therapy with no signs of sepsis. They changed the antibiotic regimen to vancomycin to cover for methicillin-resistant staphylococcus aureus (MRSA) and cefazolin. Infectious disease (ID) was consulted for antibiotic assistance. Orthopedic surgery was also consulted and assessed the patient. Their documented assessment stated no septic knee arthritis, continue antibiotics, and re-consult orthopedic surgery if symptoms worsen. 

The next day, the area of redness and tenderness was decreased, and the pain had resolved at rest. Erythrocyte sedimentation rate (ESR) remained elevated to 26,  C-reactive protein decreased to 6. The blood cultures remained negative; the syphilis screen was negative. The vital signs remained stable, without fever. The electrolytes and renal function remained stable; the liver function tests (LFTs) were normal. The medical team continued to treat with vancomycin for right knee nonpurulent cellulitis.
The patient was released from the hospital on cephalexin. The blood cultures remained negative. The question at hand is whether the above presentation warranted an inpatient stay. 

The health plan's determination is overturned. 

Inpatient hospitalization was medically necessary in this case. Based on the provided documentation, the patient failed an outpatient trial of the adequate antibiotic regimen, with antistaphylococcal penicillin and therefore required inpatient admission. The Milliman criteria for cellulitis M-70 were reviewed. Based on these criteria, clinical indications for admission to inpatient care are satisfied. The patient in this case was diagnosed with right lower extremity cellulitis and was treated with an appropriate antibiotic regimen. Despite this treatment, there was a progression of erythema, edema, and tenderness to palpation to the right lower extremity, with elevated inflammatory markers. In summary, inpatient stay is medically indicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a man. He presented to the medical center with abdominal pain of 3-days duration. He reportedly had a history of gallstones. 

The patient's vital signs identified an elevated heart rate of 109/minute, blood pressure was 133/95 mmHg (millimeters of mercury). He was tender in the epigastrium. The WBC (white blood cell) count was elevated at 12.5 K (thousand). Lipase was elevated (421). Serum alcohol level was elevated. CT (computed tomography) scan showed findings of acute pancreatitis with peripancreatic fluid collections (pseudocysts) and wall thickening of the colon. 

The patient was admitted to the hospital with the diagnosis of alcoholic pancreatitis. He was treated with IV (intravenous) fluid, NPO (nothing by mouth) status, pain medications, and serial examination. The heart rate was persistently elevated and the patient was maintained NPO (nothing by mouth) with IV (intravenous) fluid supplementation. 

The patient left the hospital against medical advice. 

Yes, the Inpatient admission was medically necessary. 

Inpatient admission was medically necessary and consistent with the standard of care. The patient was admitted to the hospital with abdominal pain, tenderness, and biochemical findings of leukocytosis. Due to his history and CT (computed tomography) findings, he was diagnosed with pancreatitis. He was appropriately managed with NPO (nothing by mouth) status, pain management and antiemetics. The care and treatment was reasonably expected to span a period of greater than 48-hours. Although he left the hospital against medical advice, this does not obviate the care provided during the period of inpatient management. 

The diagnosis of acute pancreatitis does carry the potential for rapid clinical deterioration. Treatment with NPO (nothing by mouth) status and provision of IV (intravenous) fluids during this period of nothing by mouth is a standard treatment in addition to pain management, serial examination and supportive care. This treatment is necessarily provided in the hospital inpatient environment. The records include daily progress notes, lab data and imaging results in addition to nursing and medication records. This clinical data supports that inpatient admission was medically necessary of this patient. 

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

Inpatient care was appropriate for this patient during this period of time. A lower level of care would not have been consistent with the standard of care for this patient with pancreatitis. It was reasonably expected that this patient's clinical needs for IV (intravenous) fluid, pain medications and antiemetics would span a period of greater than 48 hours. This diagnosis (based on clinical exam, labs and imaging results) and the potential for rapid clinical deterioration warranted an inpatient level of care for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excessive and Frequent Menstruation with Irregular Cycle.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the ED (emergency department) for evaluation of uterine bleeding.

On initial evaluation, the patient was afebrile, with stable vital signs, and a non-focal exam. She was noted to be anemic and had a hemoglobin of 3.6, all other labs were within normal limits. She was admitted for blood transfusion and left against medical advice.

Coverage for inpatient level of service was denied by the health plan, because the patient was not hemodynamically unstable and she had no conditions that would have required inpatient level of care.

No, the inpatient admission was not medically necessary.
Given that the patient was hemodynamically stable, with a non-focal exam and stable vital signs, she did not have any conditions that would have required inpatient level of care. The patient's care would have been more appropriately delivered at the observation level of care. There are no data to support inpatient level of care, this level of care is not standard of care, is not supported by peer reviewed data, is not supported by professional organizations and thus, it is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient did not have any acute conditions or acute or life threatening issues that would have justified inpatient level of care. She would have been more appropriate for observation. Given that the patient was hemodynamically stable, with a non focal exam and stable vital signs, she did not have any conditions that would have required inpatient level of care and her care would have been more appropriately delivered at the observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Perianal Cellulitis

Treatment acute inpatient level of care

The insurer denied coverage for acute inpatient level of care

The denial is overturned 

The patient is a male with past medical history significant for gastroesophageal reflux disease who presented to the emergency department with complaints of perianal cellulitis. Vitals on presentation included: temperature 100.4 F (Fahrenheit), blood pressure 130/90, heart rate (HR) 107, respiratory rate 19, oxygen (O2) saturation 94% (percent) on room air. Laboratory results included the following: white blood cell count (WBC) 20.4, hemoglobin (Hgb) 13.0, hematocrit (Hct) 40.4, creatinine 0.87, glucose 130.

The patient was admitted for a per-rectal cellulitis/abscess. He was treated with intravenous fluids and intravenous antibiotics (Zosyn). Computed tomography (CT) scan revealed a perianal collection consistent with an abscess. Surgery evaluated patient and performed an incision and drainage, debridement, and washout of the abscess, under anesthesia. Post-operative course was uncomplicated. The patient remained afebrile, hemodynamically stable, and was discharged on oral antibiotics to continue follow-up as an outpatient.

According to documentation, patient presented with a perirectal abscess. The patient was febrile (101.4F) with tachycardia (HR-107). Laboratory results showed an elevated WBC (20.4) and hyperglycemia (glucose-130). Additionally, the patient failed outpatient intervention with oral antibiotics. Based on above findings, hospital admission was medically necessary for 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 acute inpatient level of care is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Head Pain
Treatment: Occipital Nerve Stimulation (64590 x 1)
The insurer denied the Occipital Nerve Stimulation (64590 x 1).
The denial is upheld.

The patient is a male with occipital neuralgia. He is status post implantation of an occipital nerve stimulator with reported improvement in his condition. The provider is requesting approval for generator replacement due to failure of system.

No, the health plan should not cover the requested health service.
There are no data derived from high quality clinical trials to support that implanted neurostimulators improve outcomes for persons with occipital neuralgia (Tepper). The use of this device would be considered investigational in this clinical context.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
There are no high quality clinical trials with appropriate sham controls, appropriate patient selection and appropriate long term outcomes to support that the implanted neurostimulator is effective for this patient's condition. Standard of care guidelines do not support the use of this device for his condition (Tepper). The manuscripts provided by the attending physician (AP) are not high quality studies, reviews or guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Head Pain
Treatment: Occipital Nerve Stimulation (64590 x 1)
The insurer denied the Occipital Nerve Stimulation (64590 x 1).
The denial is overturned.

The patient is a male with severe occipital neuralgia, which has been refractory to medical treatments. The patient underwent an occipital nerve stimulator followed by permanent placement. The patient has had 80% reduction since that time. The patient was recommended revision of the generator due to it being near end-of-life.

Yes, the health plan should cover the occipital nerve stimulation.
The patient has had several years of greater than (>) 80% improvement in pain. He has clearly demonstrated improvement with the device. It would not be appropriate or medically indicated to delay the generator revision. The patient has already been treated for several years, and this is the best option for him. Therefore, revision is medically appropriate.

Yes, the occipital nerve stimulation is more beneficial.
There are no better options for this patient, as he has already demonstrated improvement with this treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Head Pain
Treatment: Occipital Nerve Stimulation (64590 x 1)
The insurer denied the Occipital Nerve Stimulation (64590 x 1).
The denial is overturned.

The patient is a male with history of occipital neuralgia. He has used a Permanent Occipital Nerve Stimulator with excellent success.  The device has provided him with several years of greater than 80% pain relief. He now has increasing difficulty charging the device. This device was previously approved by the medical director of the health plan following a peer-to-peer review. The device is nearing the end of its useful lifespan. The pulse generator needs replacement.

Yes, the health plan should cover the requested health service.

Yes, the requested health service is more beneficial.

Occipital nerve stimulation (ONS) represents an exciting therapeutic avenue for severe/refractory cases. This has become the standard of care for occipital neuralgia.

This request is for a battery (pulse generator) replacement for a previously-approved nerve stimulator. There is no documentation to indicate that the patient's status vis-a-vis his occipital neuralgia has changed, meaning that occipital nerve stimulation continues to be indicated in this case. Proper functioning of an occipital nerve stimulator requires a properly functioning pulse generator, which, as noted above, needs replacement in this patient's case.

Therefore, as this patient has been successfully using occipital nerve stimulation for several years with good results, and as the patient's pulse generator needs replacement, the health plan should cover the requested health service, in keeping with the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation. 
Treatment: Inpatient stay. 

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

The patient is a male with a history of hyperlipidemia, anxiety, depression, alcohol use, sleep apnea, and atrial fibrillation with cardioversion. There was recurrent atrial fibrillation refractory to antiarrhythmic medication and another cardioversion. He presented for elective atrial fibrillation ablation. On presentation, he was in no apparent distress. He was on outpatient anticoagulation. Electrolytes and creatinine were normal. A transesophageal echocardiogram (TEE) demonstrated no thrombus in the left atrial or appendage. The left ventricular (LV) function was normal. Vital signs and oxygen saturation were normal. He underwent a successful and uncomplicated atrial fibrillation ablation, remain stable, amiodarone was added, and was discharged. 

The inpatient hospital admission was not medically necessary. This patient underwent a successful and uncomplicated atrial fibrillation ablation. He remained stable. There was no acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, or procedure related complication such as bleeding or myocardial injury. There was no need for urgent pacemaking, no severe electrolyte abnormality, need for ongoing invasive hemodynamic monitoring, or need for ongoing prolonged intravenous medications. There was not a requirement for ongoing monitoring due to introduction of high-risk cardiac medications. In this setting, an inpatient level hospitalization, has not been established to improve cardiac outcomes. Therefore, an inpatient admission is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Assault by sharp object

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.	

The denial is upheld.
	
This is the case of a male with a history of stab wound and thoracotomy. The patient presented to the emergency department (ED) with complaints of chest pain. He was a self-referral. He was stabbed and had a chest tube placed and still had staples in his chest and was now having a lot of pain. As per the provider note, the patient stated that he was stabbed three times on his left side. He had the chest tube removed 5 days ago. The pain is 10/10 along the left sided rib cage. He denies any new trauma or fall. He denied any bleeding from the incision. The patient suffered stab wounds to the abdomen and chest. He was discharged. He reported that the oral medications he was discharged with did not help with the pain and now he is out of those, and the pain is even worse. He denied any fever or chills. He stated he spoke to the surgeon who performed the operation who told him to come to the ED. He was afebrile with stable vital signs. On exam he appeared to be in no acute distress. His breath sounds were normal.  He had a well healed thoracotomy incision with staples in place without erythema or drainage. The plan was labs, intravenous (IV) pain control, chest x-ray (CXR) and surgery consult. On hand off, the pain control improved. His hemoglobin (Hgb) was 6.9 and the plan was to transfuse one unit and they will see him this morning.

The patient was ambulating and tolerating diet. The pain was well controlled with intervention by pain management.

According to MCG (Milliman care guidelines) Health Inpatient and Surgical care 25th Edition: Chest pain ORG: M-89 (ISC) this patient could have been easily managed in an alternative setting without an acute inpatient admission as he did not have any acute serious injury now.

Furthermore, MCG Health General Recovery care 25th Edition: Pain management hospital, this patient could have been treated for pain management as it was more than 7 days since his discharge with outpatient management for his pain control. He did not need an acute admission for this or for a blood transfusion for his hematocrit (Hct) of 21. All he needed as noted by the insurer was observation with pain management.

Based upon the information provided, the hospital inpatient admission is denied as the patient should have been treated on an observation status without an acute inpatient admission. This patient presented due to pain and did have anemia which could have been easily managed without an acute inpatient admission.

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility

Treatment:  In vitro fertilization (IVF) cycle 

The insurer denied coverage for In vitro fertilization (IVF) cycle 

The denial is overturned.

According to the documentation submitted, this patient has a medical history of prior intrauterine device use, acne, depression, and anxiety who pursued fertility consultation and infertility services. The patient reported trying to conceive for months without success.  Her initial in-vitro fertilization (IVF) cycle was canceled due to poor response to stimulation. Another IVF cycle started, and the patient underwent oocyte retrieval. The patient was informed that a normal embryo was identified. She requested another IVF cycle to bank more embryos. A second IVF cycle was initiated, and additional oocytes were retrieved. An embryo from the first retrieval was implanted subsequently. 

This patient was noted to have an abnormally low ovarian reserve documented by a low AMH [anti-Mullerian hormone] level, as well as producing a low number of eggs. Furthermore, not only is it clearly documented and understood that one euploid embryo does not guarantee at least one pregnancy with a live birth outcome, but further personalized care needs to be considered when counselling and anticipating how many euploid embryos may be medically needed to complete a couple's family reproductive plan.  In addition, the older a female patient becomes, the more challenging it will be for this female to have a euploid embryo for transfer due to a higher anticipated aneuploidy rate, as well as a continued decrease in her ovarian reserve over age/time.  In other words, there would be a more effective and a higher cumulative pregnancy rate if the clinical parameters of each patient would be considered when permitting each couple to cryopreserve a reasonable number of euploid embryos based upon their age as well as ovarian reserve, etc.

This health care plan did not act reasonably and with sound medical judgment and in the best interest of this patient.  Furthermore, for reasons noted, the additional in vitro fertilization cycle should be considered medically necessary for this patient in order to provide a better medical outcome.

There are many references to support this rationale as well as this is the standard of care provided for these infertility patients electing to perform in-vitro fertilization (IVF)/pre-implantation genetic diagnosis for aneuploidy (PGT-A) for various reasons.

The insurer's denial of coverage for in vitro fertilization cycle is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic idiopathic urticaria
Treatment: Xolair

The insurer denied Xolair. 
The health plan's determination is overturned. 

This is a female with CIU (chronic idiopathic urticaria). She has failed Claritin, Zyrtec 20 milligrams (mg) twice daily (BID), Allegra and Ranitidine. She has tried Claritin in combination with Zyrtec and Ranitidine.

Xolair 150 mg/mL (milligrams/milliliter) Subcutaneous Syringe is medically necessary for this patient.

Per Bernstein et al, first line treatment for CIU includes H1 (histamine) and H2 antihistamines. The patient has tried and failed first line therapies and Xolair would be standard of care in this case. A Uniform Assessment System (UAS) score is not required for the use of Xolair per the literature or the Food and Drug Administration (FDA) package insert. This patient has failed Claritin, Zyrtec, Allegra and Ranitidine. Therefore, Xolair is indicated.