Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Minimally Invasive Lumbar Decompression (MILD) Procedure
The insurer denied Minimally Invasive Lumbar Decompression (MILD) Procedure.
The health plan's determination is upheld.

The patient is a male with intermittent neurogenic claudication due to central lumbar spinal stenosis. Prior treatment has included physical therapy, medications, as well as epidural injections. Pain continues to impact activities of daily living (ADL). Physical exam demonstrated bilateral lumbar paraspinal tenderness. Magnetic resonance imaging (MRI) of the lumbar spine with lumbar canal stenosis at L (lumbar) 3-4, L4-L5 as well as multiple degenerative changes.

The Minimally Invasive Lumbar Decompression (MILD) 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.
MILD (minimally invasive lumbar decompression) describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the MILD procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (eg, without endoscopic or microscopic visualization of the work area). Due to the unknown impact of these limitations on health outcomes, RCTs (randomized controlled trials) in appropriate patients are needed to compare this new procedure with established alternatives. According to Centers for Medicare and Medicaid Services (CMS), percutaneous image guided lumbar decompression (PILD) for lumbar spinal stenosis is not reasonable and necessary. In the first RCT to evaluate the minimally invasive procedure percutaneous laser discectomy (even though it was Food and Drug Administration (FDA) approved 24 years ago), there was no indication that this minimally invasive surgery is superior to open surgical techniques. There is insufficient data supporting this procedure over the standard traditional alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Minimally Invasive Lumbar Decompression (MILD) Procedure
The insurer denied Minimally Invasive Lumbar Decompression (MILD) Procedure.
The health plan's determination is overturned. 

The patient is a male who has chronic back pain. His back pain level ranges from 02/10 to 9/10. The pain is increased by walking and standing. Sitting improves his pain. The patient can only walk for about 300 feet or stand for 5 minute before he needs to sit down due to increased pain in his back. The patient failed conservative treatments including physical therapy anti-inflammatories and epidural steroid injections. 

Minimally Invasive Lumbar Decompression (MILD) Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has persistent severe back pain consistent with neurogenic claudication. He had failed extensive conservative treatments. Further treatments are medically necessary to improve his pain and his ability to ambulate. There are multiple well-designed MILD procedure clinical trials that showed long-term improvement in pain and function for patients with spinal stenosis from ligament flavum hypertrophy. The alternative surgical option is lumbar decompression, which is a spine surgery, associated significant risks and complications. Therefore, the MILD procedure is indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Disorder.
Treatment:  Braces.

The insurer denied braces. The determination is upheld.

The patient is a male with a Class I occlusion. He has a 5-millimeter (mm) overbite and 3 mm overjet. He has moderate maxillary and mandibular crowing. He is in the late mixed dentition stage of dental development with four remaining primary teeth. The patient's treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

There is no medical reason to correct the patient's malocclusion with braces. The patient does have a deep bite; however, that alone is not a medical necessity to treat. The photographs do not illustrate damage to the mandibular teeth or palatal soft tissue damage from their current position. Functional problems can occur in the dentition that becomes more difficult, if not impossible, to correct if not addressed in adolescence.  (1) This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) The patient has a slightly excessive overjet, but this amount of overjet does not negatively affect oral health-related quality of life. (3) Aligning the patient's teeth would provide an esthetic improvement, but it would not significantly improve the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right leg pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a female patient with hypertension (HTN), hyperlipidemia (HL), and diabetes mellitus (DM) who was admitted for a right leg atherectomy and drug coated balloon angioplasty. She stayed overnight and was discharged the next day. The medical necessity for an inpatient stay is under review.
The inpatient admission was not medically necessary. The patient had an uncomplicated procedure. There was no bleeding or hemodynamic compromise or compromise to the extremity post procedure. The post operative stay was unremarkable. Therefore, the patient could have received care at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left Sided Neck Pain
Treatment:  Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female with a history of 3 days of neck, ear and throat pain. She presented to the emergency department. She was afebrile and vital signs were stable. Her computed tomography (CT) reported a large left thyroid cyst with possible superinfection. Intravenous (IV) fluids, pain medications and intravenous antibiotic was initiated. The patient was admitted as an inpatient. The request for inpatient care was previously denied and the provider is appealing the denial.

The inpatient stay was not medically necessary.

All records were reviewed. The patient was afebrile on presentation to the emergency department with vital signs stable. There were no problems with tolerating a soft diet and there was no respiratory distress. The patient's pain was controlled, and a superinfection was ruled out. Computed tomography reported a thyroid cyst with secondary inflammation. The patient was sent home on the day after admission. Therefore, based on the information provided, the medical necessity of the inpatient care is not confirmed as the patient's care could have been achieved with a different level of care, Observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting/Abdominal Pain

Treatment: Inpatient Stay

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

The patient is a male with no significant past medical history who presented to the emergency department reporting symptoms of emesis, abdominal pain, and nausea. According to the patient, the vomiting initiated on the same morning, accompanied by a single episode of diarrhea. The abdominal pain was constant, non-localized, and radiated to the right back area. The vomiting was non-bloody and occurred once, while the diarrhea was non-bloody, and both were in the morning. The patient denied testicular pain, urinary symptoms, fever, chest pain, shortness of breath, recent illness, abdominal surgery history, and alcohol use. The patient acknowledged marijuana use, most recently the day before, and reported experiencing similar pain in the past.

The inpatient hospital admission was not medically necessary. The patient presented to the hospital with no systemic signs of inflammation, including fever, leukocytosis, or C-reactive protein elevation. No evidence of common bile duct disease was seen in the imaging studies or based on the laboratory tests. There was no need for surgical intervention, and the patient's symptoms resolved overnight. Therefore, observation was reasonable, and a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stones
Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This female adult has a history of 1.5 centimeter (cm) right proximal ureteral stone status post stent placement. A renal scan showed 23 percent (%) function in the right kidney. The patient was taken for a right kidney percutaneous nephrolithotomy (PCNL) and right stent removal. The retrograde pyelogram showed no Genito-bowel connection. The patient had a ureteroscopy and percutaneous drainage of fluid collection, and a stent was placed. A computerized tomography (CT) with oral contrast was ordered with a consult for colorectal surgery. The CT scan showed no evidence of bowel injury. On Day 2, the patient was without abdominal pain; her exam was benign, and she was started on a regular diet with serial abdominal exams ordered. 

Postoperative labs were stable, and the patient remained stable to discharge.
 
Per Milliman Care Guidelines (MCG) for Nephrostomy Percutaneous, the patient appears to meet the optimal recovery course within 24 hours post-procedure. The patient does not meet guidelines for an extended stay (post-procedure, hemodynamic instability, injury to renal pelvis with urine leakage, colonic perforation). Per Milliman Care Guidelines (MCG) for Urologic Surgery or Procedure, the patient appears to meet discharge parameters within 24 hours post-procedure. This procedure is ambulatory, with a possible overnight stay to ensure a safe discharge course in observation care. 

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably, with sound medical judgment, and in the patient's best interest. The medical necessity for an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: General Debility Due to Lumbar Stenosis
Treatment: Continued Stay in Skilled Nursing Facility

The insurer denied continued stay in skilled nursing facility. The denial is overturned.

The patient is an adult female with a history of general debility due to lumbar stenosis affecting her functional mobility and activities of daily living (ADLs). She has impairments of balance, mobility, and strength, with an increased risk for falls.

The patient's relevant past medical history includes obesity status post gastric sleeve times two (x2), severe knee and hip osteoarthritis, anxiety, bipolar disorder, hiatus hernia, depression, asthma, hiatus hernia/gastroesophageal reflux disease (GERD), fractured ribs, fractured ankle, sarcoidosis, and pulmonary embolism. Before admission, the patient was living with family and friends in a house, independent with activities of daily living, and with support from others. The patient was admitted to a skilled nursing facility (SNF) three months ago, requiring total dependence for most activities of daily living, and as of two months ago, the patient was non-ambulatory, requiring supervision for bed mobility, contact guard for transfers, and maximum assistance for static standing. She has limitations in completing mobility and locomotive activities due to gross weakness of the bilateral lower extremities, decreased stability and controlled mobility, increased pain, impaired coordination, and decreased aerobic capacity. The patient is a fall risk.

The requested health service is medically necessary for an additional two weeks due to extensive medical issues and debility.

The proposed continued stay in a skilled nursing facility is medically necessary for an additional two weeks. The patient has limitations in completing mobility and locomotive activities due to gross weakness of the bilateral lower extremities, decreased stability and controlled mobility, increased pain, impaired coordination, and decreased aerobic capacity. In addition, she is a fall risk. The patient was admitted to the skilled nursing facility three months ago, requiring total dependence on most activities of daily living. As of the last progress note dated two months ago, the patient was non-ambulatory, requiring supervision for bed mobility, contact guard for transfers, and maximum assistance for static standing. Therefore, a stay in a skilled nursing facility is medically necessary for an additional two weeks from the requested date, with re-evaluation for continued medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken Ribs
Treatment: Inpatient Hospital Admission

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

The patient is an adult male. He presented by ambulance to the hospital with severe back pain. The patient had fallen down a ramp and onto his back two days prior. The patient developed back pain and had pain with deep inspiration, prompting a call to 911 for an ambulance. The patient was taking ibuprofen and Tylenol for pain at home. A computed tomography (CT) scan of the patient's chest showed a right posterior minimally displaced 9th and 10th rib fractures. There was no associated intra-abdominal injury. There was atelectasis of the lung in the region of the rib fractures. Vital signs, including oxygen saturation, were normal in the emergency department triage note. The patient did not require supplemental oxygen during the hospitalization. The patient was admitted to the acute inpatient level of care for pain control, breathing treatments, and venous thromboembolism prophylaxis. The patient was seen and cleared by Physical Therapy. The patient's pain was controlled with oral analgesia and a lidocaine patch. Total time in the hospital was less than 13 hours. The acute inpatient level of care was denied coverage by the health plan as not medically necessary. The denial was because the patient did not have abnormal vital signs and did not require oxygen.
Additionally, surgery was not contemplated, and the patient improved while undergoing observation care. Through its agent, the hospital has appealed the denial of the acute inpatient level of care. The basis for the appeal was that the patient had severe pain. Following an emergency room physician and trauma surgeon evaluation, the patient was admitted to the acute inpatient level of care. The conclusion was that the inpatient admission was "medically necessary, unplanned, unpreventable, and was expected to span over 2 midnights." The patient's treatment included follow-up chest x-rays, follow-up lab studies, pulmonary toilet, incentive spirometry, and out-of-bed physical therapy. Medication interventions included oral narcotic medication, intravenous ketorolac, and lidocaine patch. Hydromorphone (narcotic) was ordered for severe pain. The pain was controlled, and then the patient was discharged. The appeal concludes that the inpatient admission was reasonable and consistent with the presenting symptoms and the abnormal findings in the Emergency Department.

The inpatient hospital admission was not medically necessary.

Isolated rib fracture treatment is routinely done on an outpatient basis. The intra-abdominal injury must be ruled out and was before the patient's admission. Pain control is vital in avoiding pulmonary complications. This was accomplished on the first day with intravenous Toradol, oral analgesia, and a lidocaine patch. Total time in the hospital was less than 13 hours. The care rendered did not warrant an inpatient level of care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider. You asked the Plan to pre-approve the mammogram. You say that the services are medically necessary and you have had mammograms at the provider in the past. You would like to have the procedure done there again at the in-network cost-share rate. The Plan denied your request. The Plan says it has providers that meet Medicare's requirements available within its network that can provide the same level of services. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Inpatient Hospital services provided by the practice on February 20 to February 24, 2019.You asked the Plan to pay for the inpatient hospital services. You say that the services were medically necessary.The Plan denied your request. The Plan says insufficient information was provided to support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that the services at issue are not supported in the medical record. Specifically, insufficient medical records were provided for review. The provided information does not explain how the enrollee presented to the non-contract provider, or if the services were emergent in nature. The plan made multiple attempts to secure additional records from the provider to no avail. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pay for Inpatient Hospital services provided by the practice on February 20 to February 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device without open decompression or fusion (22869 and 22870). You asked the Plan to pre-approve the device. You say that the device is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental and more research is needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device without open decompression or fusion (22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove for a pneumatic compression device (E0652). You asked the Plan to pre approve fora pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove fora pneumatic compression device (E0652
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve sacroiliac (SI) joint injections. You asked the Plan to pre-approve SI joint injections. You say that the enrollee had pain relief from a previous injection. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the prior SI joint injection was not preceded by failed conservative therapy. The Plan follows Medicare rules. Medicare rules say that SI joint injections are covered under certain conditions when they are considered medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SI joint injections. Our reviewer says that the enrollee meets the Medicare criteria for the requested SI injections. Our physician reviewer found the enrollee had a successful prior block and is taking a non-steroidal anti-inflammatory drug (NSAID). She meets all of the Medicare coverage criteria and the requested injection is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint injections have been met. Therefore,we decided that the Plan has to pre-approve sacroiliac (SI) joint injections. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occipital nerve blocks. You asked the Plan to pre-approve the blocks. You say that the doctor would not have ordered this procedure if he thought it wouldn't help. The Plan denied your request. The Plan says this is considered experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested injection is not evidence-based. It would be considered experimental and investigational. The request is therefore not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve occipital nerve blocks.