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

Diagnosis: Abdominal pain.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a history of a large pancreatic pseudocyst status post-surgical intervention. He presented to the Emergency Room (ER) with complaints of abdominal pain. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. The liver and pancreatic enzymes were normal. A computed axial tomography (CAT) scan showed a pancreatic cyst that had decreased in size and felt to be draining into the stomach. Possible gastritis was also seen. He had an endoscopy which showed some gastric inflammatory changes. Afterwards he left the hospital against medical advice (AMA). 

Based on Milliman Care Guidelines (MCG), clinical indications for admission for undiagnosed abdominal pain include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, or the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

Based on MCG, clinical indications for admission for Gastritis include hemodynamic instability, gastric outlet obstruction, perforation, peritoneal signs, severe vomiting, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had abdominal pain and required a CAT scan and endoscopy. The cyst had decreased in size. This work-up could have been done as an outpatient. The gastritis could have been treated with a proton pump inhibitor (PPI) as an outpatient. No surgical interventions were needed. He did not meet MCG criteria for admission for undiagnosed abdominal pain or gastritis. 

The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Head injury
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented after a fall and head injury. He was well until the day of admission when he was playing in a laundromat, and while looking over a table slipped and fell from a height of approximately 4 feet. As he pulled himself up, the table tipped causing him to fall backwards. As he fell, the table that he was holding also fell and his head was caught between the 2 tables. According to his mother, it took 3 people to lift the table off him. He cried immediately, and there was no loss of consciousness. He sustained a 1 centimeter (cm) laceration to the left side of his head.

The emergent hospital admission was medically necessary for this patient.
This is a very young patient who presented after a significant fall and crush injury to his head. Due to his young age and the potential severity of the injury, that was caused by a table that took multiple adults to move, the trauma team was activated. An evaluation was initiated in the emergency department which was reassuring. However, serial monitoring was felt to be needed to ensure prompt intervention if any neurologic deterioration occurred. He required frequent neurologic exams throughout the night, which could not be provided in an outpatient setting. A focused neurologic examination should include an evaluation of level of consciousness, pupillary examination, extraocular movements, funduscopic examination, deep tendon reflexes, and response to pain. Any abnormalities in this examination may suggest increasing cranial pressure that would require immediate intervention. The main concern was for potential intracranial bleeding, which would potentially require neurosurgical intervention to prevent serious morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder. 
Treatment: Inpatient Hospital. The insurer denied inpatient stay. 

The denial is upheld.

The patient is a female with a history of sickle cell disease with multiple admissions for crises, hemochromatosis, tobacco use, polysubstance abuse, and bipolar disorder. She presented to the emergency room with a two-day history of diffuse body pain that was not responsive to Percocet. She was afebrile. The oxygen saturation was 100%, and the other vital signs were normal. She was in no acute distress and was noted to be sleeping comfortably in the emergency room (ER) stretcher. Physical exam was notable only for some left hip tenderness. Labs were notable for a hemoglobin of 7.2 grams per deciliter (g/dl), white blood cell (WBC) count 18,200, and creatinine of 1.8 milligrams per deciliter (mg/dl). The chest x-ray and left hip films were unremarkable. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The ER provider concluded that the patient was suffering from a sickle cell crisis and acute kidney injury. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous fluids, Toradol, and hydromorphone. The patient appeared comfortable with treatment. The next day she left the hospital against medical advice.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. Her symptoms appeared to improve quickly with treatment in the ER. The services provided - intravenous fluids and analgesics - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, and the peer reviewed literature, the inpatient stay was not medically necessary, and the patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary/Kidney
Inpatient hospital

Diagnosis: pyelonephritis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a girl who presented with abdominal pain and fever. She was well until 1 day prior to presentation when she developed abdominal pain and fever along with emesis. She also reported some urinary frequency as well as headache and leg pain at that time. The pain was described as sharp, 8/10 in intensity, and worsening. She took acetaminophen and ibuprofen with some relief, but her symptoms returned so she was brought to the emergency department for care.
In the emergency department, she was found to have tachycardia with a heart rate of 135 beats per minute (bpm), with abdominal tenderness in the right lower quadrant and periumbilical area and some guarding. A urinalysis was obtained which revealed nitrites and leukocytes. An ultrasound was also obtained but the appendix was not visualized. Her temperature went up to 39.4 degrees C. Laboratory values revealed a low sodium of 131 mEq/L(Milliequivalents per litre ) and a C-reactive protein (CRP) of 7.5 mg/dL(Milligrams per decilitre). A computed tomography (CT) scan was then obtained which revealed evidence of pyelonephritis on the right and no appendicitis.

The Inpatient Hospital Admission was medically necessary for this patient. Hospital admission is indicated for children with urinary tract infections who are unable to tolerate oral medication, and who have urosepsis. This patient had evidence for pyelonephritis and had vomited, and presented with criteria for SIRS. Therefore, she required inpatient hospital admission for appropriate treatment and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I canine and molar occlusion
Treatment: Orthodontic Treatment
The insurer denied the Orthodontic Treatment
The denial is upheld. 

The patient is a female. The request is for orthodontic benefits for past treatment from several years ago. Photos and x-ray sent were from four years ago. The patient had a class I canine and molar occlusion, not "malocclusion" as stated.

No, the proposed treatment was not medically necessary.
The patient had a class I occlusion. She had a small (one millimeter) space between teeth #5 and #6. She had a very small (one millimeter) overlap of tooth #26 with tooth #25.

There was a small space between #5 and #6.  By the standard of care, small spaces of this size (one millimeter) can be corrected by restorative treatment (i.e. small composite), rather than moving multiple teeth to close a very small space. This type of correction of a small space is done routinely. 

There was a small overlap of tooth #26 with tooth #25.  By the standard of care, small spaces of this size (one millimeter) can be corrected with a spring retainer and a very small amount of interproximal reduction, rather than full orthodontics. This type of correction is routinely performed.

Standard of care would be for minimal treatment, such as described.

Full orthodontic treatment in this case should be considered excessive; standard of care would call for more conservative treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic abdominal pain.
Treatment: Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report.

The insurer denied coverage for the gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report.  The denial is overturned. 

This is a male patient with a history of gastritis and esophagitis. He has chronic right upper quadrant (RUQ) abdominal pain. There was an extensive work-up done. The patient's physician advised a capsule endoscopy.

The documentation indicated that the patient underwent a capsule endoscopy to determine the presence of Crohn's disease of the small intestine. The physician indicated despite thorough evaluation, the patient continued to have right-sided abdominal pain and was moving his bowels 3-4 times a day with soft stools that would sometimes float,  suggesting malabsorption. 

This patient has unexplained abdominal pain after having undergone the appropriate pre-capsule study workup such as upper endoscopy, colonoscopy, (that are in guideline algorithms), hepatobiliary iminodiacetic acid (HIDA) scan, abdominal Computed Tomography (CT) scan, breath scan, ultrasound, and abdominal magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP). The patient has abdominal pain and change in stools. The purpose of the capsule is to confirm there is no intraluminal lesion that was missed on the previous studies. Upper endoscopy and colonoscopy are in guidelines as a prerequisite for the capsule and those were obtained in this patient. With a negative capsule, the patient can reliably be told there is no significant lesion (Crohn's disease) that is life longevity altering and can be medically managed with appropriate anodynes. This should be approved.
 
The requested procedure is likely to be more beneficial than any other existing standard health service.

The carrier's denial of coverage for the gastrointestinal tract imaging, intraluminal (e.g, capsule endoscopy), esophagus through ileum, with interpretation and report should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic abdominal pain. 
Treatment: Gastrointestinal tract imaging, intraluminal (e.g, capsule endoscopy), esophagus through ileum, with interpretation and report.

The insurer denied coverage for the gastrointestinal tract imaging, intraluminal (e.g, capsule endoscopy), esophagus through ileum, with interpretation and report.  The denial is upheld. 

This is a male patient with a history of gastritis and esophagitis. He has chronic right upper quadrant (RUQ) abdominal pain. There was an extensive work-up done. The patient's physician advised a capsule endoscopy.

The patient has chronic RUQ abdominal pain.  He had a previous history of alcohol abuse but has been avoiding alcohol.  A hepatobiliary iminodiacetic acid (HIDA) scan, small intestinal bacterial overgrowth (SIBO) breath test, colonoscopy, endoscopy, abdominal computerized axial tomography (CAT) scan, and abdominal ultrasound were all negative. A magnetic resonance imaging (MRI) scan showed a small pancreatic cyst. The calprotectin was normal. The colonoscopy revealed a normal terminal ileum. On biopsy, the ileal and colonic mucosa were normal. The patient's physician advised a capsule endoscopy.

The American Society for Gastrointestinal Endoscopy has published a guideline on small bowel capsule endoscopy. The most frequent indications are evaluation of obscure gastrointestinal bleeding and the diagnosis of suspected Crohn's disease. Other indications include suspicion of small bowel tumors such as lymphoma, carcinoma, or carcinoids. 

Gastroenterology, 2017 Volume 152, Issue 3, pages 497-514 has an article titled "Clinical Practice Guidelines for the Use of Video Capsule Endoscopy." The article states that capsule endoscopy has indications for patients with Crohn's disease. It also states that in patients with chronic abdominal pain or diarrhea as their only symptoms and no evidence of biomarkers associated with Crohn's disease we suggest against the use of capsule endoscopy for the diagnosis of Crohn's disease.

This patient already had a colonoscopy with ileal biopsies that were negative for Crohn's disease. He did not have any evidence of Crohn's disease based on an extensive work-up that was performed. The scientific literature does not support the use of capsule endoscopy in this patient. Capsule endoscopy is a Food and Drug Administration (FDA) approved test. He is not a good candidate for the test because he was not having obscure gastrointestinal bleeding and did not have Crohn's disease. It is not the best treatment for this patient. 

The requested procedure is not likely to be more beneficial than any other existing standard health service.

The carrier's denial of coverage for the gastrointestinal tract imaging, intraluminal (e.g, capsule endoscopy), esophagus through ileum, with interpretation and report should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical disk degeneration and radiculopathy.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with cervical disk degeneration and radiculopathy. He was admitted and underwent anterior cervical decompression and fusion with C4-7 (fourth cervical spine vertebra-seventh cervical spine vertebra), including partial corpectomy of C6 (sixth cervical spine vertebra). The patient's medical comorbidities included hypertension, hyperlipidemia, and history of bundle branch block. The surgery took over six hours.

Yes, the inpatient admission was medically necessary.

This patient had a 3-level anterior cervical discectomy and fusion. Standard-of-care for 3-level or more would be inpatient stay. This patient was at increased risk for dysphagia and airway issues after such an extensive operation. Overnight stay would be standard-of-care among spinal surgeons. This patient also had a partial corpectomy and a lengthy operation of more than six hours.

Outpatient surgery is medically appropriate for 1- and 2-level procedures in a majority of cases, but not for 3-level, such as in this case.

Outpatient surgery would have placed this patient at risk.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sleep Apnea
Treatment: Inspire Upper Airway Stimulation System 
The insurer denied the Inspire Upper Airway Stimulation System. The health plan's determination is overturned.

The patient is a male with the history of obstructive sleep apnea. The records confirm that the patient has obstructive sleep apnea (OSA) based on the sleep study. The patient has an AHI (apnea hypopnea index) of 25.5 events per hour, with desaturation to 85% 02. Body mass index (BMI) was recorded as 31.46. Prior examination noted a deviated septum to the left and 1+ turbinate hypertrophy. This places the patient in the category of moderate sleep apnea, which is one of the most difficult patient groups to treat. The patient has a history of continuous positive airway pressure (CPAP) usage. Despite increasing pressure to 15 centimeter (cm) H20 (water) and multiple masks, the patient continued to have uncontrolled sleep apnea symptoms.

The Inspire Upper Airway Stimulation System is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
After review of the chart, and the current literature, the proposed upper hypoglossal nerve stimulation is indicated for this patient. There is Food and Drug Administration (FDA) approval of the device for obstructive sleep apnea, and the current research shows strong evidence that upper airway stimulation is an effective treatment.

The patient has failed a prolonged continuous positive airway pressure (CPAP) trial. The appropriate work up for a hypoglossal stimulator was done with a sleep endoscopy which showed lack of concentric collapse of the upper airway, and significant prolapse of the tongue during sleep. Finally, the patient is at risk for developing severe medical co-morbidities if the obstructive sleep apnea (OSA) continues to go untreated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sleep Apnea
Treatment: Inspire Upper Airway Stimulation System 
The insurer denied the Inspire Upper Airway Stimulation System. The health plan's determination is overturned.

The patient is a male with sleep apnea. Apnea hypopnea index (AHI) is 25.5. Body mass index (BMI) is 31.4. The patient cannot tolerate continuous positive airway pressure (CPAP). Multiple types of face masks have been attempted. Sleep endoscopy did not reveal concentric collapse at level of oropharynx or hypopharynx.

The Inspire Upper Airway Stimulation System is 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 attempted CPAP without relief. He has attempted multiple different types of masks. Based on the physical exam and sleep endoscopy, the patient is not amenable to other types of sleep surgeries.
Based on the patient not being able to tolerate the first line therapy for sleep apnea, CPAP, and that there are no reasonable surgical options, the Inspire Upper Airway Stimulation System is indicated. There is good literature demonstrating safety and efficacy. It is likely that the patient will have significant improvement in his sleep apnea symptoms and decreased long term morbidity if the implant is placed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic procedure
The health plan denied the treatment of braces and office visits as not medically necessary. 
The reviewer has upheld the health plan's determination.

The patient has  a diagnosis of Class II malocclusion, 2-millimeter (mm) overjet and a very slight anterior open bite, but from the premolars back the teeth are in occlusion. The upper and lower arches both have minimal crowding. The patient is treatment planned for 30-36 months of braces with extraction of four first premolars to correct her malocclusion, but treatment was denied due to lack of medical necessity. The family is appealing this ruling.

The patient has appropriate overjet and minimal crowding that does not rise to the threshold of medically necessary. Anterior open bites of a dental nature may even close spontaneously in a growing patient. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. There does not appear to be any wear present on the teeth due to the occlusion. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions and if the patient chose to have orthodontic treatment in the future there will be no negative repercussions to waiting. This open bite is dental in nature (not skeletal) given the fact that the open bite is minimal and that teeth are in occlusion from the premolars back. This case will not need surgical intervention if treatment is delayed, and it would be reasonable to evaluate if the open bite could spontaneously correct. In the absence of a functional problem, orthodontic treatment would not be medically necessary to prevent future problems and could be done at a later date for aesthetics if the patient chooses.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain
Treatment: Surgical Services
The health plan denied the requested surgical procedure. 
The health plan's determination is upheld.

The patient is a male with low back pain and degenerative changes on lumbar magnetic resonance imaging (MRI); the Intracept procedure is proposed.

I uphold, in whole, the health plan's determination of medical necessity.

No, the Intracept procedure is not medically necessary for this patient.
A prospective case series and review of literature of basivertebral and sinuvertebral nerve ablation states (in part) "A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain" [1]. The case series and review of literature is limited to a small number of subjects.
A guideline issued by the International Society for the Advancement of Spine Surgery Guideline on intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain concludes (in part) "Intraosseous ablation of the basivertebral nerve (BVN) is a relatively new minimally invasive treatment for the relief of chronic low back pain (CLBP) that is diagnosed using well-established clinical and MRI findings. The procedure is supported by level 1 evidence including 2 randomized controlled trials (RCTs) demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies" [2]. Multiple limitations of the guideline present, including:
(1) Industry funding is a potential source of study bias for the available data reviewed.
(2) Limited number of studies.
(3) Short-term follow up for the majority of studied patients.
(4) Unknown effect on the primary degenerative process.
A prospective, open-label, single-arm, multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain [3] describes improvements in pain and function following treatment, but the study is limited to 28 patients.

In short, reliable evidence shows that the consensus among qualified objective experts regarding the inherent nature of the Intracept Procedure is that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment of the condition in question and is therefore considered experimental/investigational. Experimental/investigational procedures are not considered medically necessary.