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

Diagnosis: Leg pain. 
Treatment: Pain injections (outpatient procedures - 27096 x1 
[sacroiliac joint injection], 20553 x1 [trigger point injection]). 

The insurer denied: Pain injections (outpatient procedures - 27096 x1 [sacroiliac joint injection], 20553 x1 [trigger point injection]). 

The denial is partially overturned. 

The patient is an adult female. The patient complains of pain in the leg with paresthesia. The patient reports pain worsening with activity and describes numbness and pain in the legs. The patient describes an electrical sensation in the sacrum and numbness that shoots down the buttocks, lateral aspect of the thigh, down to the calf and into the foot. The patient had completed three weeks of physical therapy with transition to home exercise program. The patient has a six-month history of tailbone pain. The patient had a prior L5-S1 laminectomy. Her baseline pain is eight out of ten (8/10). Exam revealed limited range of motion of the lumbar spine. Kemps test was negative. Sacroiliac joint was positive for distraction test, thigh thrust test, compression test, FABER test and Fortin finger test bilateral. X-ray of the sacrum shows moderate degenerative changes along the bilateral sacroiliac joints and symphysis pubis. 

The proposed sacroiliac joint injection is medically necessary. However, the proposed trigger point injection is not medically necessary. 

The health plan denied the injections stating that "continuation of injections beyond 12 months is not covered by your health plan." However, the literature does not support this statement; there are no specific guidelines stating that you cannot have injections more than 12 months apart. 

In regard to the trigger point injections for the sacroiliac joint, the request is not considered medically necessary in this case. There was no documentation of severe acute spasms or reproducible symptoms for the procedure. Additionally trigger point injections are still considered unproven. Furthermore, there have not been studies to support injections to be performed at the same time. 

In regard to the sacroiliac joint (SIJ) injections, the request is considered medically necessary in this case. The patient has tried and failed prior conservative treatments and continues to have positive findings on exam and on imaging. As such, the request is considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve Treatment
The insurer denied: Nerve Treatment
The denial is upheld.

The patient is an adult male with a history of low back pain beginning over 10 years ago. He has had multiple treatments including acupuncture, home exercises, lumbar epidural steroid injections, medial branch block injections, medication management, physical therapy, and radiofrequency ablations, acetaminophen, and NSAIDS (nonsteroidal anti-inflammatory drugs). MRI (magnetic resonance imaging) of the lumbar spine from 4 years ago shows multilevel degenerative changes of the lumbar spine, mild spinal canal stenosis, and diffuse disc bulges. The request for L (lumbar) 4, 5 Intracept was denied coverage by the health plan as not medically necessary.

The requested health service is not medically necessary.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.
At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially presented to the emergency department with concerns for chest pain and shortness of breath. Pertinent history included diabetes mellitus type 1 and Turner's syndrome. Initial vital signs revealed a temperature of 97.9oF, heart rate (HR) 97, and blood pressure (BP) 123/83. Initial examination documented the patient as alert and oriented with bilateral lower extremity edema.  The patient was placed in the hospital thereafter with an impression of hyperglycemia without diabetic ketoacidosis. Treatment included intravenous fluids, subcutaneous insulin, and supportive care.

Based on the clinical documentation provided, evidence based literature and standards of care, the inpatient hospital admission was not medically necessary.

The patient had a history of insulin dependent diabetes mellitus who presented with chest discomfort and shortness of breath. Initial evaluation found the patient to be afebrile, hemodynamically stable, and without hypoxia. Bedside ultrasound revealed a preserved left ventricular ejection fraction (LVEF) without significant abnormalities. Initial diagnostic testing revealed a negative troponin, unremarkable electrocardiogram (EKG) and unremarkable chest radiograph, but did note a serum glucose of 645, potential hydrogen (pH) 7.32, and carbon dioxide (CO2) 21. Intravenous fluids and subcutaneous insulin were provided with improvement. The admitting physician appropriately documented no evidence of diabetic ketoacidosis. Following observation care, the patient was tolerating oral intake and had a serum glucose of 208. There were no documented acute issues that required inpatient care.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have diabetic ketoacidosis, hemodynamic instability, hyperglycemic hyperosmolar state, mental status changes, severe or persistent dehydration, significant electrolyte abnormality not responsive to observation care, severe or persistent vomiting, or glucose level persistently too high for next level of care (eg, concern for redevelopment of dehydration, electrolyte abnormality), or not sufficiently stable despite observation care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: root canal, post and core, and crown for tooth #8, crowns for teeth #'s 3, 5 and 7 and crown and post and core for tooth #12.
The insurer denied root canal, post and core, and crown for tooth #8, crowns for teeth #'s 3, 5 and 7 and crown and post and core for tooth #12.
The determination is overturned.

Yes, the requested health service/treatment of root canal, post and core, and crown for tooth #8, crowns for teeth #'s 3, 5 and 7 and crown and post and core for tooth #12 medically necessary for this patient based on the documentation provided. With the presence of decay affecting the root canal of #8 there is a need for root canal therapy, replacement of the affected tooth structure through buildup and crown. With the extent of decay on teeth #3, 5, 7, 8, and 12 there is the need to replace the lost tooth structure with full coverage restorations due to the extent of decay. Buildups on #12 are required to replace the missing tooth structure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis/cholecystitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male. He presented to the ED (emergency department) with new onset right upper abdominal pain, nausea, and vomiting of 1-day duration. Comorbid 
health conditions included hypertension, hyperlipidemia, diabetes and psoriatic arthritis. At the time of presentation, the patient was without fever, and vital signs were normal. He was 
tender in the right upper quadrant. The WBC (white blood cell) count was elevated at 16 K (thousand). The complete metabolic panel identified normal liver enzymes and bilirubin. Abdominal ultrasound and CT (computed tomography) scan showed gallstones within the gallbladder with pericholecystic inflammation. He was admitted to the hospital. The patient was evaluated with surgery consultation on the same day. He was treated with IV (intravenous) fluid, NPO (nothing by mouth) status, and IV (intravenous) antibiotics. The patient underwent laparoscopic cholecystectomy the next day. The operation was performed without complication though there was significant inflammation noted. The diet was advanced following surgery and pain was controlled with oral medications. A gastroenterology consultation was requested for the evaluation of a gastric fundic lesion. The GI (gastroenterology) consultant proposed outpatient upper endoscopy in 3 to 4 weeks. The patient remained clinically stable and was discharged from the inpatient setting on the following day with planned short term follow up. The health plan denial letter references MCG (Milliman Care Guidelines) Gallbladder or Bile Duct Inflammation or Stone.

The Inpatient Hospital Admission was not medically necessary.

An inpatient level of care was not medically necessary in this case. This patient is an adult male who presented to the hospital with abdominal pain. He was determined to have 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. The indication for cholecystectomy was established on day 1. The patient admitted to the hospital. He underwent surgery to remove the gallbladder on the next day. The patient responded favorably to treatment and was stable for 
discharge from the hospital on the following 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 (emergency department) assessment, surgical assessment and monitoring, laparoscopic cholecystectomy as performed on the next day, provision of IV (intravenous) antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumed Directed Personal Assistance Services (CDPAS) from 7 days per week, 3 hours per day; 21 hours per week to 7 days per week, 12 hours per day; 84 hours per week of Personal Care Worker (PCW)
The insurer denied: Consumed Directed Personal Assistance Services (CDPAS) from 7 days per week, 3 hours per day; 21 hours per week to 7 days per week, 12 hours per day; 84 hours per week of Personal Care Worker (PCW)
The denial is: Overturned.

The patient is a female with medical history notable for history of cerebral infarction with resulting hemiplegia, dementia, and recent hospitalization. The patient was receiving 3 hours per day, 7 days per week (21 hours per week) of personal care worker (PCW) services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) of personal care services, and this was partially denied by the health plan. The plan did approve an increase to 4.5 hours per day, 7 days per week (31.5 hours per week). This denial is the subject under review.

A Uniform Assessment System (UAS) was most recently completed and was available for review. The patient was noted to be cognitively intact with modified independence. From a functional standpoint, she required maximal assistance for housework and shopping, extensive assistance for meal preparation, and limited assistance for managing finances and medications. For her activities of daily living (ADL's), she required limited assistance for bathing, dressing upper/lower body, and eating. She was independent in all other ADL's. She was occasionally incontinent of urine and continent of stool. A Mini-Mental State Examination performed on the same day scored 27/30, consistent with intact cognition. A task tool associated with the assessment recommended 20.2 hours per week to meet her personal care needs.

The health plan's determination is overturned.

The requested health of Consumed Directed Personal Assistance Services (CDPAS) from 7 days per week, 3 hours per day; 21 hours per week to 7 days per week, 12 hours per day; 84 hours per week of Personal Care Worker (PCW) service is medically necessary for this patient.
The health plan's determination is based largely off of the UAS, which is incongruent with the testimony from the physician who was treating the patient at the skilled nursing facility. The UAS reviewed was well before her hospitalization in the Fall.  The physician testified that the patient had significant declines in cognitive and functional status and now requires hands on assistance for all ADL's. This represents a significant change from the prior UAS. She will need additional hours to assist with these personal care tasks. In lieu of an updated UAS, we must rely on the testimony of the treating physician regarding her true needs. If she cannot transfer, ambulate, or perform any ADL's on her own (and has worsening cognitive status as well), then 12 hours per day is a reasonable allotment of personal care services to address her functional needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatic encephalopathy
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

 
The patient presented with confusion and constipation. She had a history of cirrhosis with hepatic encephalopathy and high ammonia levels. She has required frequent paracentesis. The Model for End-Stage Liver Disease (MELD) score was 30. She was afebrile and the vital signs were stable. There was no abdominal tenderness. A paracentesis was performed, and 4.7 liters of fluid were removed. There were no signs of infected ascites or spontaneous bacterial peritonitis (SBP). The encephalopathy was treated with lactulose and rifaximin. She was transferred to another hospital for evaluation for liver transplantation.

Milliman Care Guidelines (MCG) Clinical indications for admission for Liver Disease Complications (MCG M-570) include having hepatic encephalopathy as indicated by hemodynamic instability, tachypnea that persists after observation care, and spontaneous bacterial peritonitis. The patient had hepatic encephalopathy but did not have the other indications that are listed for admission. She also did not have infected ascites. She had chronic ascites and chronic episodes of hepatic encephalopathy. She did not have hepatorenal syndrome. The computed tomography (CT) scan did not show hepatocellular carcinoma or a portal vein thrombosis.

This patient had deteriorating cirrhosis and a rising MELD score. She required treatment with lactulose and rifaximin and then a transfer for evaluation for a liver transplant. The treatment for encephalopathy could have been given in the emergency room (ER) with observation status prior to being transferred. She did not meet MCG criteria for admission for Liver Disease Complications. 

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 hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain
Treatment: Intracept procedure codes 64628 and 64629
The insurer denied coverage for Intracept procedure codes 64628 and 64629
The denial is upheld

This is a patient with a six-month history of history of low back pain. She has had multiple treatments including home exercises, medication management, microdiscectomy, and physical therapy. Medications have included: Ibuprofen and Tylenol. The pain has had a significant impact upon activities of daily living (ADLs) such as: leisure activities and work. Nothing has provided significant sustainable relief. The severity of pain on the Visual Analog Scale (VAS) is an 8 out of 10.

She had a magnetic resonance imaging (MRI). The MRI demonstrated Modic changes at disc spaces lumbar (L) 4-L5 and L5-sacral (S)1. The request is radiofrequency (RF) ablation of the basivertebral nerves (BVN) at L4, L5 and S1.		

There is no published data on long term complication rates.  There are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

This procedure is NOT likely to be more beneficial than the standard of care.

In summary, the denial of procedure codes 64628 and 64629 and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary Ciliary Dyskinesia

Treatment: Airway clearance device (E0483RR x 3)

The insurer denied coverage for airway clearance device (E0483RR x 3)

The denial is upheld

This patient is a child with a diagnosis of Primary Ciliary Dyskinesia (PCD). There are no medical records available for this review. The therapy adherence assessment form submitted indicates that the child uses this equipment twice a week for 20 minutes. The documentation also indicates that the physician has ordered 3 airway clearance devices for this patient but the other devices that are being used are not elaborated in the documents available

The appeal request submitted does not include any clinical data indicating the frequency of the use of this device and the clinical benefit from the use of this device. There are no medical records from the Pediatric Pulmonologist who is following this child to indicate that the child is being seen for ongoing care and to document the benefit of this therapy.

Based on the available information from this submission there is inadequate documentation of the routine use of this device and whether the child is experiencing clinical benefit from the use of this device.

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 airway clearance device (E0483RR x 3) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out pulmonary embolism. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is an adult that presented to the hospital complaining of shortness of breath on exertion for a ten-day period. Past medical history was significant for diabetes mellitus and recent urinary tract infection. On arrival to the hospital vital signs were stable: Blood pressure 132/86 and Pulse 91. Physical examination demonstrated clear lungs and normal heart sounds without murmur.  Pelvic examination revealed a probable yeast infection. 12 lead electrocardiogram (ECG) revealed normal sinus rhythm with normal intervals and no ischemic segment (ST) or T wave abnormalities. The patient was admitted to the hospital for additional testing and treatment. Computed tomography (CT) chest revealed no evidence of pulmonary embolism. Echocardiogram revealed preserved left ventricular function and the patient was discharged home.

This patient presented with dyspnea and abdominal pain and a past medical history of diabetes mellitus. Her pretest probability of coronary artery disease was low. (Reference 1) Utilizing the HEART (History, ECG, Age, Risk factors, and troponin) score she was considered low risk. (Reference 2) Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score she 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. In conclusion, this patient could have been treated at a lower level of care. 

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 hospital admission is not substantiated.