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

Diagnosis: Klippel-Trenaunay syndrome, varicose veins with intermittent claudication, weakness, neuropathy.
Treatment: Power Wheelchair (PWC) Group II; (K0823).
The insurer denied the Power Wheelchair (PWC) Group II; (K0823).
The denial is overturned.

The patient is a male with history of chronic leg pain, edema, deformed right ankle, neuropathy and weakness, with severe varicose veins in both lower extremities status post varicose surgeries to both legs and no longer operable, and having moderate difficulty with walking associated with intermittent claudication. In addition he has Klippel-Trenaunay syndrome, carpal tunnel syndrome and thoracic/lumbar radiculopathy. 

The request is for a Powered Wheelchair (PWC), group II, which was denied by the health plan because the patient doesn't have Mobility Related Activities of Daily Living (MR-ADLs). The treating physician appealed this denial because patient is said to be disabled.

Yes, the proposed Power Wheelchair (PWC) Group II; (K0823) is medically necessary.
The power wheelchair is medically necessary because the patient has chronic leg pain, edema, deformed right ankle, neuropathy and weakness, with severe varicose veins in both lower extremities status post varicose surgeries to both legs and no longer operable, and having moderate difficulty with walking associated with intermittent claudication. In addition, the patient has Klippel-Trenaunay syndrome, carpal tunnel syndrome and thoracic/lumbar radiculopathy.  The power wheelchair is also medically necessary because it is not for the convenience of the patient but medically necessary to enable the patient with his condition and extensive weakness to continue to navigate paths, etc towards improving his mobility and accessibility as part of his activities of daily living.  The patient has multiple issues affecting his mobility and also carpal tunnel syndrome that will making propelling a wheelchair more difficult.

No, the health plan did not act reasonably with sound medical judgment which was not in the best interest of the patient because the powered wheelchair is medically necessary and likely to be more beneficial than any other option as stated above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This patient is a female with past history of asthma who presented to the emergency room with worsening shortness of breath and wheezing. In the emergency room, the patient was found to have asthma exacerbation. In the emergency room, the patient received intravenous steroids, bi-level positive airway pressure (BIPAP), and nebulization treatment. The acute in patient level of care was denied. This denial is being appealed. 

At the time of admission, the patient was off bi-level positive airway pressure (BIPAP), was treated with intravenous steroids, intravenous antibiotics for pneumonia and was on supplemental oxygen. The patient was able to speak in full sentences. By day two, the patient's breathing was at baseline. The patient was able to tolerate ambulation, she was able to speak in full sentences and was able to take oral medications. The patient was discharged home.

No, the proposed inpatient admission was not medically necessary.
The patient was admitted to the hospital for asthma exacerbation and pneumonia. At the time of admission, the patient was off the bilevel positive airway pressure (BIPAP), was treated with intravenous steroids, intravenous antibiotics for pneumonia and was on supplemental oxygen. The patient was able to speak in full sentences. By day two, the patient was hemodynamically stable. The patient's oxygen levels were above 94% (percent), the patient's breathing was at baseline. The patient was able to tolerate ambulation; the patient was able to speak in full sentences and able to take oral medications. The admission was not medically necessary as the patient improved significantly within 24 hours. The patient could have safely and effectively received care a lower level.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Body pain (amplified musculoskeletal pain
syndrome [AMPS])
Treatment: Acute rehabilitation treatment, pre-service
The insurer denied the Acute rehabilitation treatment, pre-service
The denial is overturned

This patient is a female with history of amplified pain syndrome. The patient has been recommended for acute inpatient rehabilitation. The patient developed pain in both hands and hips approximately two years ago. Based on the review of medical records, the patient received aqua therapy and as well as psychological services that did not yield improvement in her symptoms.  

The initial request for acute inpatient rehabilitation stay has been denied by the health plan due to the lack of information meeting criteria for acute inpatient rehabilitation interventions. The letter of medical necessity was written by the skilled medical providers in support of intensive amplified musculoskeletal pain syndrome interdisciplinary program at the tertiary care facility.

Yes, the proposed acute rehabilitation treatment is medically necessary.
There is a sufficient evidence submitted in this case in support of acute inpatient rehabilitation intervention for this patient with long standing history of amplified pain syndrome symptoms. This patient will be capable to tolerate 15 hours per week of structured rehabilitation interventions provided by the skilled professionals with clearly defined goals and in a patient-centered family-oriented environment.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
In this case, the patient does not have options for outpatient treatments. The patient is independent but experiencing pain and difficulty with activities of daily living (ADLs) management. Amplified musculoskeletal pain syndrome (AMPS) treatment should be done in the settings of acute inpatient rehabilitation with the specialized well supported and structured program including interdisciplinary care. Initial length of stay should be considered for two weeks with subsequent re-review of goals and expected improvements.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Intracept Procedure (Intraosseous Basivertebral Nerve Ablation).
The insurer denied the Intracept Procedure (Intraosseous Basivertebral Nerve Ablation). The health plan's determination is upheld. 

The patient is a male with low back pain. The pain has been present for many years. The pain is rated 8/10 out of 10. The patient denies any weakness in the lower extremities. Physical exam reflexes are normal, facet tenderness is mild bilaterally, and sacroiliac tenderness is mild bilaterally. Magnetic resonance imaging (MRI) lumbar spine showed multilevel degenerative changes.

The Intracept Procedure (Intraosseous Basivertebral Nerve Ablation) 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 has complaints of low back pain. This procedure is not currently recommended or supported by evidence-based medical literature. 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 this 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. There is lack of substantial improvement in pain and function noted and there is lack of long-term data to support this procedure. Given the above, the proposed Intracept Procedure (Intraosseous Basivertebral Nerve Ablation) 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: Low back pain.
Treatment: Intracept Procedure (Intraosseous Basivertebral Nerve Ablation).
The insurer denied the Intracept Procedure (Intraosseous Basivertebral Nerve Ablation). The health plan's determination is overturned. 

This is a male who has a long-standing history of low back pain. His pain is constant-achy pain across lower back. Pain level is 8-10/10. His pain is worse with lower back extension or standing from a seated position. No tinging/numberless in the lower extremities is noted. He underwent conservative treatments including physical therapy (PT), lumbar epidural steroid injections and lumbar medial branch radiofrequency ablation (RFA) with minimal improvements. He has tried Tylenol, and muscle relaxants with mild temporary pain relief. Physical exam (PE) revealed mild tenderness in bilateral lumbar regions. A magnetic resonance imaging (MRI) show Modic type 1 and type 2 changes from L (lumbar) 3 to S (sacral) 1. The issue is whether this patient will benefit from the Intracept procedure.

The Intracept procedure is likely to be beneficial for this patient.
The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention for vertebrogenic pain. This patient has persistent back pain consistent with vertebrogenic pain. He had tried conservative treatments including pain medications, PT, epidural injections and lumbar medial branch RFA with minimal improvement. He is a candidate for this Intracept procedure based on current clinical evidence, his clinical presentations and MRI findings. The other potential option is lumbar fusion, which is clearly more invasive and associated higher risks and complications. Given these facts, the Intracept procedure is appropriate as the next step treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Intracept Procedure (Intraosseous Basivertebral Nerve Ablation).
The insurer denied the Intracept Procedure (Intraosseous Basivertebral Nerve Ablation). The health plan's determination is upheld. 

The patient is a male with chronic lower back pain (LBP) for several years which has been progressive and described as bilateral constant dull aching back pain. The patient used acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants as well as physical therapy and multiple epidural steroid injection (ESI) and Lumbar Medial Branch Block radiofrequency ablation (RFA) with minimal as well as temporary relief. The patient review of symptoms and past medical history was non contributory. 

The Intracept Procedure (Intraosseous Basivertebral Nerve Ablation) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. With respect to this case, it is not clear if the patient has significant physical limitations due to his chronic LBP. The requesting physician notes that the patient's pain is debilitating but there is no ODI (Oswestry disability index) score or specific explanation as to the degree of limitations. The procedure is in its infancy but has received at least Food and Drug Administration (FDA) 510k clearance meaning that is safe and effective compared to currently available therapies; but this does not represent a full approval or speak to the overall effectiveness since other therapies have significant limitations. Our understanding of pain and LBP continues to evolve but there remains significant limitation in both evaluating and treating these patients. However, there are also limitations of the available literature including mostly device company funded studies. As a result many clinicians are including STIR (short tau inversion recovery) imaging to evaluate for endplate edema which may be more indicative of patients who respond to the procedure. Many providers are finding mixed results, but identifying patients who will benefit most, as well as continued research in the future will hopefully determine the utility of this procedure. Given this patient has failed multiple other conservative therapies, he has Modic changes, his pain continues, surgical options would not guarantee relief or are appropriate at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Dupixent. 
The denial is overturned in whole.

The patient is a male with severe atopic dermatitis, treated with topical steroids, topical calcineurin inhibitors, Eucrisa and Dupixent. His provider is requesting continuation of Dupixent. The patient has involvement to neck, trunk and extremities. He also has allergies and asthma.

At issue is the medical necessity of Dupixent.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Dupixent is medically necessary for this patient.

Dupixent is under investigation in children as young as 6 months and preliminary data show no safety concerns with substantial efficacy. The patient has already been stable on Dupixent for almost 2 years, and the risk of destabilization of the patient if Dupixent is discontinued is too risky, and would not be within the standard of care. It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded. Furthermore, Dupixent is a much more appropriate choice in the current coronavirus (COVID) pandemic, as this patient is too young to receive the vaccine. Oral immunosuppressants such as cyclosporine would pose a much greater risk of severe COVID disease in this patient with asthma. Dupixent is not immunosuppressive and is therefore a better choice for this patient.

Therefore, the requested health service/treatment of Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Mini Stroke
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. She presented after a syncopal episode with subjective left sided weakness. Her medical history had only been notable for asthma. There was concern for a possible stroke. CTH (computed tomography of head) and CTA (Computed Tomographic Angiography) of the head and neck both returned unremarkable.

The patient underwent echocardiogram. However, the patient elected to leave the hospital AMA (against medical advice) before MRI (magnetic resonance imaging) could be completed.

A request had been made for coverage of services at the inpatient level of care. The request was denied by the health plan based on MCG (Milliman care guidelines) criteria.

No, the Inpatient admission was not medically necessary.
The patient presented to the hospital with complaints of a syncopal event. The initial suspicion had been for a conversion disorder versus stroke. The patient's work-up did not reveal a stroke. The patient's weakness was otherwise only noted to have been transitory in nature (it self-resolved).

There was no evidence of significant sustained neurological deficit. There was no indication of an infection, metabolic finding of concern or significant hemodynamic instability. There was no deterioration in the patient's condition from the time of presentation. The patient's evaluations as performed were otherwise most consistent with those generally provided in the observation level of care. In as much, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan's decision was made appropriately based on standard industry guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth. 
Treatment: D6010 Implants Tooth #4, #5 and #8. 

The insurer denied the D6010 Implants Tooth #4, #5 and #8. 
The denial is upheld. 

The patient is a male. The request is for dental services for implants on teeth #4, #5, and #8.  Per the Provider's assessment, teeth #4, #5, and #8 need implants because the patient has a sensitive gag reflex and is unable to wear partials consistently and has dysphagia (difficulty swallowing). 

The health plan denied the claim because "it is not medically necessary". The provider is appealing based on the findings and the proposed treatment plan. 

No, the requested dental implants for teeth #4, #5, and #8 are not medically necessary.
There are different options to replace missing teeth. Implants are the most invasive and technical of the options.  The Provider does not sufficiently state why the other methods of replacement, namely fixed prosthodontics, would not be an option.  There is no evidence presented that there is contraindication to other methods of replacement; therefore, the proposed dental implants are not medically necessary.

Yes, the health plan acted reasonably with sound medical judgement and in the best interest of the patient. 

Implant placement is the most invasive and technical of the three options of teeth replacement; therefore it should be shown why the other options are not viable and that implants are the only option for this patient given the patient's specific circumstances. There is no documentation from the Provider or the patient's primary care physician to support any medical condition that dictates that implants are the only replacement option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied inpatient stay. 
The denial is upheld.

This is the case of a male who presented  with abdominal pain and was found to have uncomplicated acute appendicitis. He underwent laparoscopic appendectomy, without complications. The patient was discharged that same day to home in improved condition. The issue in this case is whether an acute inpatient admission was medically necessary.

The health plan's determination is upheld in whole.

An inpatient stay was not medically necessary. This is a healthy patient who whose uncomplicated appendicitis was promptly recognized and treated. He received definitive treatment with a laparoscopic appendectomy expeditiously. He had no complications and was stable for discharge. All of this occurred on the same calendar day. This is not an inpatient only procedure. It is well studied that for appropriate patients with acute appendicitis that is uncomplicated, an inpatient stay is not necessary. This is not a new concept. In a study from five years ago on outpatient laparoscopic appendectomy for acute appendicitis, the authors state, "Outpatient laparoscopic appendectomy can be performed with a high rate of success, low morbidity, and low readmission rate. This protocol has withstood the test of time." There could not be a more ideal patient for such a scenario as this patient. He is a healthy male with uncomplicated appendicitis who tolerated surgery well. The patient could have been managed at a lower level of care status as supported by the records and the peer reviewed literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay 
Treatment: D2751 White Glass With Metal Crown, Tooth 8 and 9, Pre-service 
The insurer denied the D2751 White Glass With Metal Crown, Tooth 8 and 9. 
The denial is overturned. 

The patient is a male. The request is for dental benefits for white glass with metal crown on teeth # (number) 8 and #9. The x-rays reveal significant decay on the distal aspect of tooth #8 approximating the nerve chamber, and tooth #9 shows a large existing filling on the distal aspect approximating the chamber. 

The health plan denied the claim because it says that a crown is not needed to fix these teeth. 

Yes, the proposed treatment of white glass and metal crown is necessary on teeth #8 and #9. 

The patient presented with significant decay on tooth #8 that is near to the nerve chamber, and on tooth #9, there is a large existing filling that approximated the nerve chamber. 

A request was made for endodontic treatment (root canal); that treatment was approved. Typically, the standard of care is for crown placement after root canals are done to restore function as well as to prevent the tooth from fracturing. 

The condition of the teeth are well supported by the x-rays that were submitted, showing the very large area of decay and the large existing filling on these teeth. There will also be additional tooth structure loss from the access necessary to perform the root canal therapy. 

Considering all these factors, full coverage crowns are medically necessary to restore these teeth. 

The health plan approved the root canal treatment; after a tooth has a root canal it becomes brittle because the nerves and blood supply are removed during the process. Therefore, by not approving the crowns, this jeopardizes the health of these teeth as they will be subject to fracture and eventual tooth loss.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mood disorder; severe alcohol use disorder. 
Treatment: Inpatient admission. 

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

The patient is a male. His history includes diabetes, hypertension, depression, and alcohol use disorder. He presented with depression and suicidal ideation. He had increasing alcohol consumption. He denied history of alcohol withdrawal seizures.

The patient's vital signs were as follows: Temperature 97.4, pulse 105, respiration rate 19, blood pressure 159/85, oxygen saturation 97%. The patient's exam was remarkable for being tearful. His labs were as follows: WBC (white blood count) 4.25, H/H (hemoglobin/hematocrit) 14.6/41.8, Plt (platelets) 40, BMP (basic metabolic panel) within normal limits. His abdominal US (ultrasound) revealed no active disease. 

The patient was admitted with 1:1, CIWA (clinical institute withdrawal assessment) protocol, and psychiatry consult. Psychiatry consult diagnosed the patient with mood disorder and severe alcohol use disorder. Psychiatry recommended 1:1 due to suicide risk. 

Day two, the patient's vital signs were stable. The plan was to continue current treatment. 

Day three, the psychiatrist recommended low dose disulfiram and discontinuation of 1:1. The plan was to continue CIWA (clinical institute withdrawal assessment) protocol. 

Day four, the patient's vital signs were stable. The patient was cleared for discharge. 

No, the Inpatient admission was not medically necessary. 

This patient with a history of alcohol use disorder was admitted after reporting suicidal ideation and increased alcohol consumption. The patient was hemodynamically stable. He had mild tachycardia. He did not have nausea, vomiting or tremors. He did not have history of seizures. He did not have active comorbid medical conditions. He remained clinically stable during hospital stay without signs of alcohol withdrawal. Psychiatry determined he was not suicidal. He was not receiving intervention that required an acute inpatient level of care. 

Per the MCG (Milliman Care Guidelines) Adult Substance-Related Disorders, inpatient admission was not medically necessary for alcohol withdrawal because the patient did not have elevated risk due to historical or comorbid factor with: History of delirium due to alcohol or sedative withdrawal; History of repetitive seizures due to alcohol or sedative withdrawal; Intrinsic seizure disorder; or Other significant medical history. 

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