Persius/hicric huggingface dataset:
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 diagnoses of low back pain and spondylosis without myelopathy or radiculopathy (lumbar region). 
According to the letters of appeal submitted, the provider notes that they disagree that the procedure is investigational and state that this procedure fills a treatment gap for those patients that do not receive adequate relief from traditional conservative methods for the treatment of chronic back pain and don't have instability to indicate that fusion is the appropriate treatment. The letter states that the patient has tried and failed conservative treatment without relief and they strongly disagree with the decision to deny, stating that it is inconsistent with pain for other spinal ablations. It was stated that the patient has chronic low back pain that began several years ago and has tried activity modification, home exercise and physical therapy. Medications have included acetaminophen, diclofenac gel, Medrol Dosepak, muscle relaxants, non-steroidala anti-inflammatory drugs (NSAIDs), opiates. The pain is affecting her activities of daily living and is rated at 9/10 and nothing has provided significant relief. The provider noted that she had a magnetic resonance imaging (MRI) scan demonstrating Modic changes at the lumbar (L) 3 and L4 vertebral bodies and believes this is the cause of the patient's chronic back pain.
The plan was for the Intracept procedure and this is under review.

The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation 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.
The patient is noted to have a history of chronic back pain. The provider states the patient has failed conservative treatment, though it was also noted the patient underwent lumbar radiofrequency ablation with 80% (percent) improvement in pain bilaterally and also reports 40% improvement in pain with medications. The provider feels that the patient's pain is coming from Modic changes and she was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation).
Although some studies have shown promising results, additional studies are needed to establish the safety, efficacy and health improvement. Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required." This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe and effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
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 whose diagnoses included low back pain, spondylosis without myelopathy or radiculopathy (lumbar region). Records show that the treating provider recommended the patient undergo the Intracept procedure, which was denied by the insurance carrier as experimental and investigational. The treating provider is appealing this determination.
The treating provider submitted letters of appeal outlining that the patient has a history of chronic low back pain present for several years. It was noted that prior treatment has included activity modification, physical therapy and home exercise. The patient has tried medications including acetaminophen, oral and topical nonsteroidal anti-inflammatory drugs, muscle relaxants, opioids and Medrol Dosepak. It was noted pain is affecting the patient's ability to perform activities of daily living and nothing has provided significant or sustained benefit. The provider reports the patient had magnetic resonance imaging (MRI) demonstrating Modic changes at the lumbar (L) 3 and L4 vertebral bodies and believes this is the cause of the patient's chronic back pain. It was recommended that the patient undergo the Intracept procedure and this is under review.

The proposed health service or treatment Intracept 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.
The patient has a history of chronic back pain that has failed medication, physical therapy, home exercise and activity modification, though there are multiple other treatment options that can be attempted. The patient reportedly had significant improvement following a lumbar radiofrequency ablation by 80 percent (%) pain relief, which would suggest that the facet joints are the primary pain generator. There are a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Surgical Procedure on the Stomach and Related Inpatient Admission.
The insurer denied Surgical Procedure on the Stomach and Related Inpatient Admission.
The health plan's determination is overturned.

This patient is a woman under consideration for bariatric surgery. The patient has attempted weight loss with conventional exercise programs. Unfortunately, she has not been successful with significant sustained weight loss.

The proposed laparoscopic sleeve gastrectomy and inpatient admission is medically necessary for this patient.
This patient has a body mass index (BMI) in excess of 35 with weight related comorbid health conditions that include hypertension. She is prescribed Nifedipine for this condition. She also has Rheumatoid arthritis. These weight-related health conditions will respond favorably to the sustained weight loss associated with laparoscopic sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has been granted medical (cardiology and pulmonary) clearance.

Inpatient admission is the standard of care associated with bariatric surgical interventions such as laparoscopic sleeve gastrectomy. This operation is a major surgical intervention that carries substantial risk and requires appropriate post-surgical care and treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Social Day Care (SDC): Daily - 1 day(s) - 2 days per week - for a total of 2 days per week
The insurer denied Social Day Care (SDC): Daily - 1 day(s) - 2 days per week - for a total of 2 days per week.
The determination is overturned.

This is a female patient with a medical history notable for dementia. The patient is approved for 1 day per week of social day care (SDC). The patient and her care team requested approval for 2 days per week.
The patient's physician provided a letter of support for this appeal. The letter states that regular attendance at adult day care "is crucial to meet social, cognitive and emotional needs, and provide respite for the caregiver." The patient has had decreased social engagement since a vertebral surgery. The physician states that increasing attendance at adult day care will improve her quality of life.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person and place only. She had a mini-mental state examination score of 22/30, consistent with mild dementia. Her recall was 1/3 words at 5 minutes and she was not able to complete procedural tasks. She requires varying levels of assistance for all Instrumental activities of daily living (IADLs) . She requires extensive to maximal assistance for all activities of daily living. She is occasionally incontinent of urine. Compared to a prior UAS, the patient showed a cognitive and functional decline.
At issue is the medical necessity of Social Day Care (SDC): Daily - 1 day(s) - 2 days per week - for a total of 2 days per week.

The requested health service of Social Day Care (SDC): Daily - 1 day(s) - 2 days per week - for a total of 2 days per week is medically necessary for this patient.
The patient is exhibiting signs of dementia as diagnosed by her Mini-Mental State Examination (MMSE) and her physician. She is primarily cared for by her family, but her care needs are expected to be continuous and unscheduled throughout the day as indicated by the Uniform Assessment System (UAS) which shows that she requires hands-on assistance for all care activities. Social Day Care has been shown to help improve well-being in adults with dementia and also to reduce caregiver burden. One study found that "this service contributes to the enhancement of activities and social support, prevents isolation, and enhances practical and cognitive functioning as experienced by the users (Strandens et al)." Trettetieg et al also found that "Day care relieves family caregivers by meeting the person with dementia's needs for social community, nutrition, physical activity, and structure and variety in everyday life." The physician letter of medical necessity outlines this potential benefit for the patient. Therefore, the requested increase is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: unresponsive episode/overdose
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of an unresponsive episode. Pertinent history included epilepsy and polysubstance abuse. Initial vital signs revealed a temperature of 35.9oC, heart rate (HR) 110, blood pressure (BP) 145/118, respiratory rate (RR) 26, and peripheral capillary oxygen saturation (SpO2) 99% on room air. Initial examination documented the patient as alert and oriented without focal neurologic deficits. Electrocardiogram (EKG) revealed sinus tachycardia without acute ischemic changes. Initial laboratory testing revealed a white blood cell count (WBC) 14.9, Hemoglobin (HGB) 12.0, platelets (Plt) 376, Na (sodium) 137, K (potassium) 3.1, carbon dioxide (CO2) 29, blood urea nitrogen (BUN) 13, Cr (creatinine) 1.68, Lactic acid 1.0, and Troponin 0.117. Urine drug screen was positive for benzodiazepine and cocaine. 

The inpatient hospital admission was not medically necessary. The patient had a history of long-standing epilepsy and polysubstance abuse who initially presented after an unresponsive episode. Upon arrival, she was alert, oriented, hemodynamically stable, without hypoxia, and without acidosis. Serum creatinine was slightly elevated as was a troponin, however, electrocardiography and CT head imaging were unremarkable. Urine drug screen was positive for benzodiazepines and cocaine. Treatment plan thereafter included oral Keppra and additional diagnostic testing in the form of an echocardiogram, cardiac stress test, and electroencephalogram (EEG). The echocardiogram and cardiac stress test were unremarkable. The EEG revealed findings suggestive of epilepsy, but without evolution to an active seizure. Following observation care, mentation was at baseline, laboratory abnormalities were resolved or at baseline, and a medication regimen was established.
The hospital course was prolonged after the patient was noted to be vaping an unknown substance with subsequent lethargy then a trip and fall with patient-stated seizure. This was not witnessed. Additional diagnostic testing was performed and also unremarkable. The hospital course was prolonged further due to opioid withdrawal treated by oral methadone. After a long course without persistent hemodynamic instability, acutely abnormal diagnostic testing, witnessed recurrent seizures, or significant laboratory abnormalities, the patient was discharged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 Braces. 
The insurer denied coverage for D8080 Braces. 
The denial is overturned. 

This patient is under the care of an orthodontist to treat severe crowding. There are upper and lower incisors outside the arch. The patient has a large overjet and deep overbite. The occlusion is class two. 

The patient meets Handicapping Labio-Lingual Deviation (HLD) criteria for coverage. There is a deep overbite and large overjet. The labiolingual spread is 5-6 millimeters (mm). There is crowding to both arches. The calculated HLD number is 29 and this meets criteria. This qualifies for full arch orthodontia. Therefore, the D8080 Braces is considered medically necessary for this patient. 

Cousin, T. (2020), "Introduction: State Medicaid agencies rely on treatment need indices to identify patients with orthodontic medical necessity. The Handicapping Labiolingual Deviations (HLD) index is the most common orthodontic index in the United States. States which have adopted the HLD index have modified it without supporting validation studies. The purpose of this study was to validate all state-modified HLD indices currently used in the United States and to investigate the implementation of the Washington state HLD modification, HLD(WA)... Results: There were many qualitative differences among state-modified HLD indices. State-modified HLD indices had a mean between-state agreement of 79.1%, a mean sensitivity of 41.6%, and a mean specificity of 92.9%. The optimal point thresholds were lower than the current point thresholds for all state modified HLD indices. When the implementation of HLD(WA) was evaluated, we found a mean approval rate of 35.4% and a mean denial rate of 52.4%. While total mean approval and denial rates were not significantly different among clinic types, there were significant differences among clinic types in the number of applications approved and denied according to index guideline versus reviewer override (p<.01). Conclusions: Our results suggest that state modified HLD indices fail to identify a considerable percentage of handicapping malocclusions. There is also a lack of consensus among state Medicaid programs on what constitutes a handicapping malocclusion. In addition, our study indicates that there are differences in approval and denial rates among clinic types." 

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 D8080 Braces is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
Patient is an adult female with a history of Asthma, hypertension, and Obesity who presented to the emergency department (ED) with complaints of shortness of breath (SOB) and Cough x (times) 1 day. Vital signs at presentation were Temperature 98.8 degrees Fahrenheit, Heart rate 122, Respirations 24, Blood Pressure 174/107, Oxygen (O2) saturation 93% (percent) on Room Air, peak expiratory flow (PEF) 280. Lungs revealed bilateral wheezing. White Blood Cells (WBC) were 16,600 and Venous Blood Gas 7.3 / 48.

Patient was admitted for Asthma exacerbation. Patient was treated with intravenous fluid (IVF), Steroids, Bronchodilators (BD), and Magnesium. Patient was also started on IV (intravenous) antibiotics - Azithromycin and Rocephin. Patient had some electrocardiogram (EKG) changes, but Troponins were negative. Patient had a computed tomography (CT) Angiogram which was negative for pulmonary embolism. No infiltrates or Effusion. No other acute pathology. Patient was continued on IV Steroids and BD. Diagnosis was Asthma exacerbation and Bronchitis.

Patient remained afebrile and stable after admission. Patient was improved. Patient was tolerating food and fluids and was in no acute distress.

This patient did not need acute inpatient hospitalization. She should have been placed in Observation while diagnostic testing and treatment were continued. Observation period could be for up to 48 hours. Heart attack and pulmonary embolism were ruled out. Patient did not have Pneumonia and asthma was improving. Patient could have been discharged home on oral (PO) antibiotics, PO Steroids and BD (Bronchodilators) with close follow-up in the outpatient setting. Patient was afebrile, not hypoxic and was tolerating PO.

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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
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 (PMH) of polysubstance abuse who was admitted with complaints of (c/o) a one-day history of right leg swelling. His vital signs were unremarkable. The physical exam was notable for right lower extremity (RLE) erythema and tenderness to palpation (TTP). Lab work was notable for a white blood cell count (WBC) of 12.9. Imaging studies included a RLE radiograph which showed no acute fracture or dislocation, a chest x-ray (CXR) which showed clear lung fields. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with uncomplicated cellulitis and was treated with antibiotics. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with complaints of (c/o) a one-day history of right leg swelling. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, he did not meet systemic inflammatory response syndrome (SIRS) criteria, there was no animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with intravenous (IV) antibiotics for uncomplicated cellulitis, and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and cough
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the emergency room with cough and wheezing for two days. This did not improve with home Symbicort and frequent Albuterol MDI (metered dose inhaler). In the emergency room, the patient's temperature was 97.9, pulse 74, blood pressure 127/70, and 
oxygen 99% (percent). Chest X-ray revealed no acute finding. She had a history of chronic obstructive pulmonary disease (COPD), hypertension, diabetes mellitus, and gastroesophageal reflux disease (GERD). In the emergency room, she received Duonebs x3 and intravenous Solumedrol with improvement. The patient received intravenous Rocephin and Zithromax. The patient was admitted from the emergency room with shortness of breath and cough with "no wheezing on physical examination." On day #2, the visit report still noted shortness of breath and "wheezing." Lungs were noted as positive for wheezing bilaterally. She 
received Nebs treatment x3 and intravenous Solumedrol x3.
On day #3, no acute complaints were noted, but report on exam noted bilateral expiratory wheezes and labored breathing on exam. The patient received Nebs treatment x3 and intravenous Solumedrol x2. On day #4, the patient was noted to feel better." The physical exam reported, "bilateral expiratory wheezes and labored breathing on exam." The patient received Nebs treatment x3 and intravenous Solumedrol x1. On day #5, the patient was discharged. The physical exam reported, "bilateral expiratory wheezes and labored breathing on exam." The nurse's note revealed no distress and clear breath sound since day of admission.

The inpatient admission was not medically necessary.

The patient was admitted with shortness of breath and wheezing. Her symptoms improved after day of admission. Her treatment did not required hospitalization. The patient only required a few breathing treatments. She had no problem in oral intake, and her medication could have been given by mouth instead of intravenously. There was no indication that her condition was worsening, such as requiring more frequent breathing treatments, requiring higher oxygen or requiring breathing support, or any evidence of infection. The chest X-ray was reported clear. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Pressure; Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with end stage renal disease on peritoneal dialysis and hypertension. The patient was admitted to the hospital with chest pain and hypertension. The patient was treated with intravenous diuretics, oral antihypertensive medications were optimized, and peritoneal dialysis was maintained for fluid removal. There was a denial of an acute inpatient level of care as not meeting Milliman Care Guidelines (MCG) criteria. The physician is appealing the determination.

The requested health service was not medically necessary.

The patient was admitted to the hospital with chest pain and hypertension. She was treated with intravenous diuretics, oral antihypertensive medications were optimized, and peritoneal dialysis was maintained for fluid removal. Based on available data, there was no documentation of altered mental status that was severe or persistent. There was no hemodynamic instability, cardiac arrhythmias of immediate concern, or significant respiratory findings that were severe or persistent despite observation care treatment. There were no clinically significant electrolyte abnormalities or metabolic abnormalities that were severe or persist despite outpatient or observation care treatment or acute treatment of renal failure (e.g., dialysis) not feasible at a lower level of care. Based on available data, there was no documentation of acute or worsening target organ damage as indicated by one or more of the following: hypertensive encephalopathy (e.g., altered mental status), cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure (e.g., pulmonary edema), aortic dissection, increased creatinine (new) with reduction of more than 50% (percent) in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, or seizure or other acute or worsening end organ damage due to severe hypertension. Based on available data, these were not present; therefore, inpatient level of care was not recommended.