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

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

This is a male patient with a past medical history of cirrhosis secondary to alcohol and diabetes mellitus type 2 (DM2) who presented to the emergency room (ER) with abdominal pain and an increased abdominal girth following a burn to his abdomen. He also complained of lower extremity edema. He was hypertensive but otherwise hemodynamically stable on admission and was afebrile. He had ascites and abdominal tenderness but the rest of his physical examination was normal. He had thrombocytopenia and abnormal liver tests consistent with cirrhosis. He had a diagnostic paracentesis in the ER that did not reveal spontaneous bacterial peritonitis (SBP). He was admitted as an inpatient started on diuretics. He had a therapeutic paracentesis with the removal of 3 liters of ascitic fluid. He was discharged home with outpatient follow up. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of Inpatient hospital stay is not medically necessary for this patient. The patient could have been managed at a lower level of care.
This patient did not have evidence of systemic inflammatory response syndrome (SIRS) or sepsis. He was hemodynamically stable and did not have peritoneal signs or acute on chronic liver failure. He did not have evidence of severe hepatic encephalopathy or massive ascites or spontaneous bacterial peritonitis or hepatic hydrothorax or variceal bleeding to warrant inpatient level of care. Therefore, he could have been observation status.
Ascites is the most common complication of cirrhosis and also the most common complication that leads to hospitalization. Patients often require a combination of pharmacological and non-pharmacological therapies to adequately manage ascites and fluid retention. Controlled salt intake and oral diuretics are the backbone of first-line therapy. In patients with alcoholic cirrhosis, cessation of alcohol use can lead to drastic improvement in ascites and other reversible components of alcoholic liver disease. Large volume paracentesis is a safe and effective therapy for patients presenting with tense ascites and can be done in the outpatient setting. However, this procedure should be followed by sodium restriction and diuretics for patients who are diuretic sensitive.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The insurer denied intraosseous basivertebral nerve ablation. 
The determination is upheld. 

This is a female patient with complaints of chronic low back pain. She denies trauma or injury. The pain presents across the low back and will radiate to the bilateral hips and down all aspects of the thigh. The patient has tried multiple medications: Tylenol, non-steroidal anti-inflammatory drugs (NSAIDs), tramadol, baclofen, and meloxicam. Her past medical history is noncontributory. The physical examination notes negative standing leg raise, tenderness to palpation over the lumbar spine, tenderness to palpation over the sacroiliac joint, bilateral sacroiliac joint pain, Faber's positive, Fortin's finger positive, thigh thrust positive. 
A magnetic resonance imaging (MRI) scan of the lumbar spine which notes multilevel degenerative disc disease with neural foraminal narrowing. The suggested diagnosis is vertebrogenic pain. Intraosseous basivertebral nerve (BVN) ablation is under review. 

The proposed treatment is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to Becker, et. al : "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)." Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. 
As cited above, the Becker. et.al trial indicated only a 17 patient observational study.
These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. 
According to Smuck M , et. al " Accordingly, longer-term follow-up may be needed to observe changes in opioid behaviors as demonstrated by a secondary analysis of data from the previous sham-controlled randomized controlled trial (RCT) of BVN ablation that showed opioid reduction in the subgroup reporting improvements in pain during long-term follow-up." 
Long term outcomes have not been elucidated demonstrating health outcomes, pain, and disability measures. In addition, no United States guidelines based on research recommend this treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The insurer denied intraosseous basivertebral nerve ablation. 
The determination is overturned. 

This is a female patient with a history of chronic low back pain. She was seen by a nurse practitioner. It was noted that she has been treated with Tylenol, non-steroidal anti-inflammatory drugs (NSAIDs), Tramadol, Lyrica, gabapentin and baclofen. She was also treated with therapy. A magnetic resonance imaging (MRI) scan of the lumbar spine  revealed degenerative and Modic changes. A request was made for intraosseous basivertebral nerve (BVN) ablation and this is under review. 

The proposed health service or treatment intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. A review of available up-to-date publications utilizing BVN ablation in the treatment of vertebral pain suggests that there is quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to evidence that BVN RFA (radiofrequency ablation) is superior to conservative care for pain reduction, at least at 3-month follow-up. Also, there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious adverse events (AEs) based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.
Appeal type: Medical necessity
Decision: Overturned

Skin
Radiation Therapy

Diagnosis: vitiligo
Treatment: phototherapy
The insurer denied phototherapy
The health plan's determination is overturned. 

The patient is a male with vitiligo, treated with topical steroids, topical calcineurin inhibitors, calcipotriene, and Opzelura. The provider is requesting phototherapy. 

Phototherapy is medically necessary for this patient.
There is extensive support in the literature for the use and efficacy of phototherapy, specifically nbUVB (narrow band ultraviolet B (UVB)), in vitiligo. Vitiligo is a disorder of pigmentation, in which patients experience a loss of functional melanocytes. Therefore, patients lack pigment protection in vitiliginous areas of the skin. Patients are at increased risk of sunburns and skin cancer. The aims of vitiligo treatments are repigmentation and stabilization of the depigmentation process. Phototherapy is standard of care in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain and right upper extremity pain
Treatment: Total Disc Arthroplasty (code: 22856)
The insurer denied: Total Disc Arthroplasty (code: 22856)
The denial is upheld.

This patient is an adult male with neck pain and right upper extremity pain. He had received physical therapy, nerve blocks, epidural steroid injection (ESI), and medications without benefit. The duration was years. The patient also had an extensive evaluation for shoulder problems. He had undergone surgery for labral pathology. The patient's physical examination was significant for limited motion, positive right Spurling's, and sensory loss on the right at C6. The magnetic resonance imaging (MRI) report was significant for minimal and paracentral disc herniation to C6-7. The foramina were patent. There was no central or foraminal stenosis. The physician recommended total disc replacement (TDR) C6-7.

The proposed treatment is not medically necessary.

The medical records are inconsistent to substantiate the C6-C7 level as a pain generator. There have been treatments provided to several body sites without improvement. There has been a 
long-term history of shoulder pain with surgery. There have been several injections and services for unclear neck pain, i.e., the pain was localized to the sternocleidomastoid muscle. There have been injections with radiofrequency ablation for facet disease. The most important finding was the lack of nerve root or cord compression. Simply stated, the foramina were clear. At the very most, a degenerate segment is present which is not an absolute indication for arthroplasty. The indications for surgery are very specific for magnetic resonance imaging (MRI) correlation to substantiate surgery. There was no magnetic resonance image correlation; thus, surgery would not be indicated. The proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

Diagnosis: cholecystitis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a previously healthy woman who presented with upper abdominal pain and vomiting. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was elevated at 14.9. The complete metabolic panel identified normal liver enzymes and normal bilirubin. Abdominal ultrasound showed gallstones within the distended gallbladder and no gallbladder wall thickening. The common bile duct was 2- millimeter (mm) in diameter. She was admitted to the hospital with the diagnosis of cholecystitis.

An inpatient hospital admission was not medically necessary. This patient is a woman who presented to the hospital with abdominal pain and vomiting. She was determined to have symptomatic cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. She underwent surgery to remove the gallbladder. The patient responded favorably to treatment and was stable for discharge from the hospital on the first post-surgical day with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, surgical assessment and monitoring, laparoscopic cholecystectomy, provision of IV antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is the case of a patient that presented to the hospital with chest pain and shortness of breath. Pain was intermittent for a three-month period but on the day of presentation pain was more severe (8/10) and radiated to the left scapula.  Past medical history was significant for gastroesophageal reflux disease (GERD).  On arrival to the hospital vital signs were stable(Blood pressure 142/106, Pulse 89). No abnormal findings were noted on physical examination. 12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities. Serum troponin levels were not elevated. The patient was admitted to the telemetry ward for monitoring and treatment.  Serial troponins remained negative. The patient was treated with proton pump inhibitor medication and discharged with cardiology follow up.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain and a past medical history GERD. The patient's pretest probability of coronary artery disease was low (Reference 1).  Utilizing the HEART (History, ECG, Age, Risk Factors, Troponin) score, the patient was considered low risk (Reference 2). Utilizing the thrombolysis in myocardial infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is a patient with a past medical history significant for hypertension who presented to the emergency room with complaints of shortness of breath and right leg pain and swelling. 

Vitals on presentation included: Temperature (T) 100 Fahrenheit (F), blood pressure (BP) 150/81, pulse (P) 99, respiratory rate (RR) 16, oxygen (O2) saturation 100%.

Laboratory results showed: white blood cell count (WBC) 17.57, hemoglobin (Hgb) 13.9, hematocrit (Hct) 40.1, potassium 3.1, creatinine 1.33, glucose 107, creatine phosphokinase (CPK) 252, urinalysis showing moderate leukocyte esterase.

The patient was empirically started on intravenous (IV) antibiotics (vancomycin). A computed tomography (CT) scan angiogram showed no evidence of pulmonary embolism, no acute infiltrates or effusion. Doppler was negative for deep vein thrombosis (DVT). Infectious Diseases was consulted and switched antibiotics to Ancef. The patient remained afebrile, hemodynamically stable, and was discharged to continue oral antibiotics as outpatient. 

According to documentation, patient presented both respiratory and musculoskeletal complaints.  The patient had a low grade fever, tachycardia and laboratory results showed multiple abnormalities including elevated WBC, low potassium, elevated creatinine, elevated CPK and positive leukocyte esterase on urinalysis. Based on the complexity of this presentation, hospital admission was medically necessary for intravenous antibiotics and additional diagnostic testing.   

Prior determination of denial of inpatient hospital admission is reversed.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a patient with a past medical history of anxiety, arthritis, and gastroesophageal reflux disease (GERD) who presented to the emergency department with complaints of fever, shortness of breath, and neck pain.

Vitals on presentation included: Temperature 99.8 degrees Fahrenheit, Blood Pressure 136/83, Pulse 108, Respiratory Rate 22, oxygen (O2) saturation 97% (percent) on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 7.9, hemoglobin (Hgb) 11.4, hematocrit (Hct) 36.3, glucose 134, creatinine 0.7, and d-dimer 1948.

The patient was empirically started on intravenous (IV) antibiotics (vancomycin, ceftriaxone, ampicillin, acyclovir) for possible meningitis. Lumbar puncture was attempted but unsuccessful. A computed tomography (CT) angiogram was negative. The patient's chest x-ray showed patchy infiltrate at left base. Head CT scan showed no abnormalities. The patient did have a lumbar puncture eventually, fluoroscopically guided that was negative for bacterial cause. Cerebrospinal fluid (CSF) WBC was predominantly lymphocytic. The patient was treated symptomatically with intravenous fluids, anti-emetics and pain medications. The patient improved clinically, remained afebrile, hemodynamically stable. The patient was discharged to continue management as an outpatient management.

According to medical records, patient presented with complaints of severe headaches. Otherwise, the patient was afebrile, hemodynamically stable.  Laboratory results were unremarkable except for an elevated d-dimer. The patient's WBC (white blood cell count) was normal. Lumbar puncture showed WBC with lymphocytic predominance. Based on the above abnormal findings, the patient met criteria for observation level of management.  

Prior determination of denial of inpatient admission is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission from is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Kidney Failure/ESRD (end stage renal disease). 
Treatment: Surgical Procedure on Kidney. 
The health plan denied: Surgical Procedure on Kidney. 
The determination is overturned. 

The patient is a male with past medical history of atrial fibrillation on Eliquis, coronary artery disease (CAD), congestive heart failure (CHF), and chronic kidney disease (CKD) stage 4 who presented to the dental clinic for medical clearance for a kidney transplant, per protocol. The dental examination shows no teeth and no signs of infection. He has completed imaging studies and procedures, and he also has been approved by the renal transplant committee. He was cleared for the kidney transplant from a dental standpoint.
At issue is the medical necessity of the surgical procedure on his kidney (kidney transplant). 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of Surgical procedure on Kidney is medically necessary for this patient. 
Kidney transplantation is well established as the best treatment option for end-stage kidney disease. It confers not only a better quality of life but also a significant survival advantage compared to dialysis. However, despite significant improvement in short-term kidney transplant graft survival over the past three decades, long-term graft survival remains suboptimal. Concerns about the possible contribution of chronic calcineurin inhibitor (CNI) nephrotoxicity to late allograft failure and other serious adverse effects of currently used immunosuppressive agents (especially corticosteroids) have led to increasing interest in developing regimens which may better preserve kidney allograft function and minimize other immunosuppression-related problems without increasing the risk of rejection. The availability of newer immunosuppressive agents has provided the opportunity to formulate such regimens. Approaches to this end include minimization, withdrawal, or avoidance of corticosteroids and CNIs. Currently, replacement of a CNI with a mammalian target of rapamycin inhibitor while continuing mycophenolate and discontinuation of corticosteroids within the first post-transplant week is being increasingly utilized. Belatacept-based, CNI-free immunosuppression is an emerging alternative approach to avoiding CNI-mediated nephrotoxicity. Recent studies suggest that chronic alloimmune damage rather than chronic CNI nephrotoxicity is the major contributor to late kidney allograft failure. The implications of this finding for the use of CNI minimization protocols are also discussed (Prashar 2016).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Oral Appliance
The insurer denied an Oral Appliance.
The determination is overturned.

This is a male patient with obstructive sleep apnea who was prescribed an oral appliance to help treat the condition. The patient had a home sleep study with an apnea hypopnea index (AHI) of 13 and tried and was intolerant to continuous positive airway pressure (CPAP). He has a history of gastroesophageal reflux disease (GERD) and dyslipidemia. At issue is the medical necessity of an oral appliance.

The requested treatment with an oral appliance is medically necessary for this patient.
The current literature does support the use of oral appliance therapy to treat mild to moderate obstructive sleep apnea especially in the setting of patients who have tried and been intolerant to continuous positive airway pressure (CPAP). Oral appliance therapy has been a well-studied, well validated and widely recommended treatment of obstructive sleep apnea. The patient had obstructive sleep apnea (OSA) and was intolerant to CPAP. An oral appliance is a reasonable and noninvasive treatment for OSA that is well studied and well tolerated by patients. This is a medically necessary treatment for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lymphoma

Treatment: PET Scan with CT for Attenuation (Position Emission Tomography with Computed Tomography - pictures of inside body)

The insurer denied coverage for PET Scan with CT for Attenuation (Position Emission Tomography with Computed Tomography - pictures of inside body)

The denial is overturned


This is an adult who is on Humira which can cause lymphoma. The patient has significant lymphadenopathy in left (L) upper limb. The patient needs biopsy of the node for diagnostic and treatment management. Position Emission Tomography (PET) scan can guide exactly which node needs to be biopsied.

As mentioned by attending physician, the reason the biopsy has not been performed is that the Position Emission Tomography with Computed Tomography (PET/CT) is needed to confirm the exact lymph node to biopsy. The PET/CT will light up the exact lymph nodes which have the highest uptake in fluorodeoxyglucose (FDG). The lymph node which is the brightest is the lymph node that will be biopsied. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for PET Scan with CT for Attenuation (Position Emission Tomography with Computed Tomography - pictures of inside body), visits/units requested 1 is substantiated.