Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Orthopedic
Surgical services

Diagnosis: back pain
Treatment: basivertebral nerve ablation
The insurer denied basivertebal nerve ablation. The health plan's determination is upheld. 

This patient is a female who has low back pain for years. Her pain is across the lower back with sharp pain in the right L (lumbar) 5 and S (sacral)1 distribution. She is on CBD (cannabidiol) and non-steroidal anti-inflammatory drugs (NSAIDs) with some pain relief. Her pain level is 6/10. She previously underwent acupuncture, chiropractic manipulation, facet injections and epidural injections. A prior epidural injection provided her with significant pain relief. 

Thermal Destruction of intraosseous Basi-vertebral nerve (Intracept) 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 Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient responded to the prior epidural injection. Physical exam (PE) showed positive facet loading and straight leg raise tests. The MRI (magnetic resonance imaging) report showed minimal disc bulge at L (lumbar) 4/5 with facet arthrosis at L3/4 L4/5 and L5/S 9sacral) 1 but no Modic changes.
Truumees's study supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the primary inclusion criteria is Type 1 or Type 2 Modic changes on an MRI at one or more vertebral bodies from L3 through S1. In addition, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were in the exclusion criteria.
Given this patient's clinical presentation, MRI findings of spinal stenosis, disc bulge and facet arthropathy, and the current clinical evidence, it is unlikely that the proposed Intracept Procedure will be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation, Chronic Obstructive Pulmonary Disease

Treatment: Personal Care Assistance a total of 40 hours per week

The insurer denied coverage for Personal Care Assistance a total of 40 hours per week

The denial is upheld 

This is an elderly patient with chronic medical problems including atrial fibrillation, chronic obstructive pulmonary disease (COPD) and osteoarthritis.  The patient lives alone in a private residence and their sons provide daily informal care. The patient is currently receiving 23 personal care assistance (PCA) hours/week and requested an increase to 40 PCA hours/week, which was denied by the insurer and currently under review.  

The Uniform Assessment System (UAS) report is reviewed.  The patient's cognition is described as minimally impaired.  The patient is able to call 911 in an emergency and also activate their Personal Emergency Response System (PERS) if needed. The patient reportedly requires extensive to maximal assistance for much of their Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping.  Extensive assistance is reportedly needed for bathing and lower body dressing.  Limited assistance is reportedly needed for upper body dressing, locomotion, toilet transfer/use and ambulation (however, observed ambulating independently with and without a cane indoors). The patient is otherwise independent for personal hygiene, bed mobility and eating. The patient is fully continent of bladder and bowel.  There has been no reported decline in their activities of daily living (ADL) status or reported falls over the prior 90 days.  

The letter from the patient's treating physician indicates the patient is "a very disabled person" and documenting the past medical history was reviewed.  However, the associated office visit notes were not submitted for review.  The patient's condition and functional deficits are not at a level or unpredictable as to require an increase PCA of 40 hours/week; particularly given that her sons provide daily informal care.   Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the 23 PCA services week, informal care from family and Personal Emergency Response System (PERS).   

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

From a physical medicine and rehabilitation perspective, the requested increase PCA to 40 hours per week is not medically necessary.  

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

The medical necessity for Personal Care Assistance a total of 40 hours per week is not 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 with a history of asthma who presented to the emergency department (ED) with complaints of shortness of breath (SOB) and wheezing. On the way to the ED he was given Dexamethasone 10 milligrams (mg), magnesium and Duo nebs. At presentation to ED vital signs were normal and oxygen (O2) saturation on room air was 95% (percent). The patient was described to be comfortable and in no acute distress with normal heart sounds. Lung sounds were positive for bilateral wheezing. 

Peak expiratory flow was 300.  Labs were within normal limits, troponin was negative. Chest x-ray showed no acute pulmonary disease. Electrocardiogram was normal. The patient was continued on steroids, bronchodilators (BD) and Azithromycin. Influenza and Covid negative.

It appears that this patient was initially in Observation. His exam revealed that he was speaking full sentences and not short of breath. Peak expiratory flow was 300. He was continued on steroids, BD and oral (PO) antibiotics. The patient remained stable after admission and was discharged home the next morning.

This patient did not need acute inpatient hospital admission. He could have been placed in observation status while diagnostic testing and treatment were initiated. Observation period could be for up to 48 hours. Patient was afebrile and stable. Improved with treatment in ED. He was admitted as his pulse was reported around 110. The patient was otherwise in no acute distress. Tachycardia is an effect of treatment with Nebulizers, Terbutaline and beta agonists which were given repeatedly to the patient.

This patient could have been placed in observation and treatment of asthma initiated and once stabilized he could have been discharged home on PO meds with close follow-up in an outpatient setting.

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: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult male with a past medical history that includes obesity, sleep apnea, recent COVID and diverticulitis. He presented to the emergency room (ER) with chest pain, which had resolved prior to evaluation, after aspirin and nitroglycerin. He tested positive for influenza A, having had recent symptoms suggestive of that diagnosis. He was discharged the following day after a reassuring cardiac workup.

The patient was evaluated in the emergency department (ED). He had noted 20 minutes of chest pain. She planned a conservative workup with serial enzymes, serial electrocardiograms (EKGs), and telemetry monitoring in the CDU (an observation chest pain unit - aka Cardiac Decision Unit).

Cardiac enzymes were not consistent with an acute event. Normal chest X-ray was noted. An echo and a lipid panel were planned, as was a cardiology consultation. The positive Influenza A result was noted, but no intervention was felt necessary. An outpatient workup for sleep apnea was considered.

The Cardiology consultant noted a history of hyperlipidemia and hypertension which were not reported elsewhere. Chest pain was felt to be atypical, with Acute Coronary Syndrome (ACS) unlikely, probable demand ischemia from influenza. Outpatient stress test was recommended.

There is no mention of the patient leaving against medical advice (AMA).

The ED physician felt the pain was atypical, and a conservative approach involving what appear to be an observation unit (the CDU) was planned. Their plan for workup and treatment was fairly generic, and there was no indication in their documentation that it would not be completed within 48 hours. 

Chest pain was the admission diagnosis. A commonly used tool in assessing the necessity for workup of admission in the setting of chest pain in the Emergency Department (ED) is the HEART (a score to determine the risk for cardiac event) score. The patient's HEART Score was probably 3, with 1 point for age of 57, 1 point for slight troponin elevation, and 1 possible point for trivial electrocardiogram (EKG) abnormalities. This HEART score of 3 put him in the low-risk category, indicating that discharge to home was appropriate. This score has been validated multiple times, including analyses comparing it favorably to other methods of risk evaluation. 

Neither the emergency department team, the medicine team, nor the cardiology team felt that the patient required a prolonged hospitalization to evaluate his atypical chest discomfort. 

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: Experimental/Investigational
Decision: Overturned

Diagnosis: Tourette's syndrome. 
Treatment: Deep Brain Stimulation (brain stimulation of the subthalamic nucleus or globus pallidus). 
The insurer denied coverage for Deep Brain Stimulation (brain stimulation of the subthalamic nucleus or globus pallidus). 
The denial is overturned. 

This is a young adult female where the treating provider has diagnosed the patient with Tourette's Syndrome associated with self-injurious behavior (SIB). The patient was evaluated by the neurosurgeon and had a neuropsychological evaluation. The patient was also diagnosed with obsessive-compulsive disorder (OCD), learning disability, and attention deficit hyperactivity disorder (ADHD). The treating provider is requesting therapy with deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus, which is under review. 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes. 

Deep brain stimulation of the subthalamic nucleus or globus pallidus has final approval from the Food and Drug Administration FDA for diagnosis of Obsessive-Compulsive Disorder (OCD). 

The patient is diagnosed with OCD and Tourette's which share overlapping symptoms. 

The patient is a good candidate for deep brain stimulation of the subthalamic nucleus or globus pallidus. 

Deep brain stimulation of the subthalamic nucleus or globus pallidus is the best available treatment for this patient at this time. 

The patient has failed multiple other treatments and is severely impaired by her symptoms. 

Surgical risks are considered and are thought to be less than standard treatment which has not worked. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient because the standard care has not helped. 

Scientific literature contains randomized controlled studies in peer-reviewed literature supporting a result of improvement in health outcome for DBS in Tourette's syndrome. 

"Embedded closed-loop deep DBS was feasible, safe, and had a comparable outcome to conventional DBS for the treatment of tics."(Cagle, J. N., et al 2022) 

"This study extends previous findings providing data showing that globus pallidus (GPi)-DBS does not adversely affect cognitive domains such as memory, executive function, verbal fluency, attention, psychomotor speed, and information processing. These results indicate that GPi-DBS does not produce any cognitive deficits."(Cappon, D., et al 2019) 

"Patients showed an average decrease of 37% (p = 0.0063) in the total tic severity at their first postoperative visit. At their latest visit, their scores achieved significance, decreasing from preoperative scores by an average of 50% (p = 0.0014)."(Dowd, R. S., et al 2018) 

In summary, the denial of deep brain stimulation of the subthalamic nucleus or globus pallidus and coverage for the requested service/treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Tourette's syndrome
Treatment: Deep Brain Stimulation (brain stimulation of the subthalamic nucleus or globus pallidus). 
The insurer denied coverage for Deep Brain Stimulation (brain stimulation of the subthalamic nucleus or globus pallidus). 
The denial is overturned. 

This is an adult female with Tourette's syndrome (TS), since she was a child. Symptoms include self-injurious motor tics. The patient has tried and failed various medications. The request is for brain stimulation of the subthalamic nucleus or globus pallidus, which is under review. 

Deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus is likely to be more beneficial for this patient. 

The patient has severe Tourette's with self-injurious tics that has been refractory to medical management. Deep Brain Stimulation has been successful for many patients with Tourette's. DBS should only be used in adults, treatment resistant, and severely affected patients, which is the case here. The patient is the ideal candidate for this type of treatment. 

Roth, J. (2018), "Atypical antipsychotics (e.g., risperidone, ziprasidone, olanzapine, aripiprazole) are often the first-line treatment; typical antipsychotics (e.g., haloperidol, pimozide, fluphenazine), benzodiazepines (clonazepam) and tetrabenazine are employed less frequently. Alpha adrenergic agonists (clonidine, guanfacine), the selective noradrenaline re-uptake inhibitor, atomoxetine, and the amphetamine-like stimulant, methylphenidate, are useful in patients with tics and Attention Deficit Hyperactivity Disorder (ADHD); selective serotonin re-uptake inhibitors can be useful in individuals with tics and Obsessive Compulsive Disorder (OCD). Botulinum toxin can be effective in focal tics. In severe, treatment-resistant TS, deep brain stimulation may be beneficial." 

Xu, W., et al., (2020), "Tourette syndrome (TS) is a childhood-onset neuropsychiatric disorder characterized by the presence of multiple motor and vocal tics. TS usually co-occurs with one or multiple psychiatric disorders. Although behavioral and pharmacological treatments for TS are available, some patients do not respond to the available treatments. For these patients, TS is a severe, chronic, and disabling disorder. In recent years, deep brain stimulation (DBS) of basal ganglia-thalamocortical networks has emerged as a promising intervention for refractory TS with or without psychiatric comorbidities." 

Schrock, L. E., et al., (2015), "Tourette syndrome DBS, though still evolving, is a promising approach for a subset of medication refractory and severely affected patients."  This is the best available treatment for this patient; the literature supports its use in this clinical circumstance, and the patient is a good candidate for this procedure. 
Based on the above, the insurer's denial is overturned. Deep brain stimulation of the subthalamic nucleus or globus pallidus services is likely to be more beneficial than any other standard therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rash
Treatment: Inpatient hospital admission
The insurer denied: Inpatient hospital admission
The denial is upheld.

The patient in this case is an adult female with lung cancer on treatment with chemotherapy. She presented to the emergency department with a thigh rash. This had developed over two days and gradually worsened. She had no pain or other symptoms.
The patient's exam revealed an area of erythema along the right upper inner thigh. The area measured 1x1 centimeters, and there was no tenderness, fluctuance, or induration. Vital signs were unremarkable. Labs were notable for white cell count of 28, though she had no fever or signs of sepsis. She was treated with broad spectrum antibiotics and admitted to the hospital. Potassium was low at 2.6. She was treated for hypokalemia and evaluation revealed no infection. She was discharged on day #3.

The inpatient hospital admission was not medically necessary.

This patient had a small rash and an elevated white cell count. Of note, she had been treated with Neulasta days before this emergency department visit. Records indicate that she had no significant symptoms, normal vital signs, and no signs of sepsis or infection. She did have hypokalemia. While she required treatment for hypokalemia, she did not require acute care inpatient admission. She could have been safely cared for in an observation setting to ensure that her potassium corrected and 
that she did not develop any signs of worsening infection. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety, depression, cognitive decline, coronary artery disease, and cancer
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) services for a total amount of 30 hours/week
The insurer denied the increase in CDPAP services for a total amount of 30 hours/week.
The denial is upheld.

This adult female has medical conditions that include anxiety, depression, cognitive decline, coronary artery disease, and cancer. The denial of an increase in consumer directed personal assistance program (CDPAP) services for a total amount of 30 hours/week is being appealed. The health plan approved 15 hours/week. Uniform Assessment System (UAS) evaluation completed 10 months ago shows modified independent cognition and functional status; extensive assistance with personal hygiene, meal preparation, shopping and housework; limited assistance with dressing; supervision with bathing; and independent with bed mobility, eating, locomotion, walking, toileting, and phone use. The patient has frequent bladder incontinence. A letter from the provider reports several medical and psychiatric conditions. The patient lives alone and requires assistance with ambulating, bathing, meal preparation, and light housework.

The proposed treatment is not medically necessary. 

Personal assistance services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services. This patient has multiple chronic conditions. The denial of an increase in CDPAP services for a total amount of 30 hours/week is being appealed. The health plan approved 15 hours/week. UAS evaluation completed 10 months ago shows the patient is independent with bed mobility, eating, locomotion, walking, toileting, and phone use. She requires assistance with personal hygiene, meal preparation, shopping, housework, and dressing. The appeal letter notes several chronic conditions and needs of assistance with ambulating, bathing, meal preparation, and light housework. The information provided does not support that the patient has functional needs requiring an increase in CDPAP from 15 to 30 hours/week. The approved CDPAP 15 hours/week is appropriate to meet this patient's needs for assistance with ADLs. The proposed CDPAP 30 hours/week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal pain, perirectal abscess
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department with severe perirectal pain. The patient had a past medical history of a hemorrhoidectomy and pilonidal cyst resection. He reported the pain was constant and felt like a spasm. His vital signs demonstrated hypertension, a low-grade temperature to 100.1 degrees Fahrenheit. The examination did not demonstrate anal fissures, hemorrhoids or abscesses. A computed tomography (CT) scan demonstrated some thickening of the rectal wall.  The patient was hospitalized to undergo a rectal exam under anesthesia (EUA). The patient underwent the EUA which demonstrated a peri-rectal abscess. This was drained. There were no complications. The patient was discharged later that day. At issue is the medical necessity of an inpatient admission.
The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient had a clear need for a surgical procedure, but did not have a need for inpatient level of care. There is no physician documentation of the need for an inpatient level of monitoring, complex diagnostics, or treatments other than the surgery. There is no evidence of patient specific problems that would require an inpatient level of care to meet medical needs or to assure patient safety. There is no evidence of a complicating event that occurred before, during, or after the patient's care that would require inpatient level of care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right elbow pain. 
Treatment: CPT (Current Procedural Terminology) 73218 - Magnetic Resonance Imaging (MRI). 
The insurer denied coverage for CPT 73218 - Magnetic Resonance Imaging (MRI). 
The denial is overturned. 
 
This is an adult female with right elbow pain. She had completed a home exercise program of 6 weeks without improvement. She was found to have tenderness to the proximal region of pronator mass. An x ray was reported as unremarkable.  The physician diagnosed a right forearm strain and recommended magnetic resonance imaging (MRI) of forearm. 

The medical records were consistent for pathology. The physician performed a complete history and physical examination. There was documentation of failure to improve over a course of greater than 6 weeks. There was documentation of physician interpretation of X ray. 

Indications for an MRI are the need to obtain additional information if diagnostic studies are inconclusive. There should be a course of conservative management. The MRI can assist in determining specific diagnosis which can alter treatment plan. 

Based upon the above, medical indications for the MRI have been met. 

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 CPT 73218 - Magnetic Resonance Imaging (MRI), special kind of picture of the arm without contrast (dye) is substantiated.