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

Diagnosis: Dental Issues.
Treatment: Braces and monthly visit.
The insurer has denied the braces and monthly visit.
The determination is upheld. 

The patient is a male with a Class II occlusion and a moderate overbite. The maxillary and mandibular arches both have space. The treatment planned is for 30-36 months of orthodontics to correct his malocclusion. At issue is the medical necessity for braces and monthly visits. 

The patient has minor space in both arches. His bite is deep but there is no indication of damage to the incisors or the palate in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided that there is severe soft tissue damage (or any soft tissue damage) for the patient.

There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite; however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct a deep bite and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood, so it is not as if he will lose the ability to correct his malocclusion should he choose to do so as an adult.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept procedure
The insurer denied the Intracept procedure. 
The health plan's determination is upheld.

The patient is a female with chronic lower back pain (LBP) for greater than 1 year. The patient's pain history is complicated and includes significant complaints of (c/o) cervical spine radicular symptoms, degenerative disease, and motor deficits resulting in an anterior cervical discectomy and fusion (ACDF). 

Nerve 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.
With respect to this case, the patient has limitations due to her chronic LBP. Although it is not clear how much her limitations are due to her cervical spine disease versus (vs) her LBP. The requesting physician notes that the pain is significant and limits activities of daily living (ADLs) but there is no Oswestry disability index (ODI) score, which is the gold standard for studies evaluating this procedure. Additionally, the magnetic resonance imaging (MRI) report notes endplate degeneration and Modic changes but it is not noted which type, i.e. type 1, 2, or 3. The type of change represents the continuum of inflammation and may predict the potential outcomes.

Therefore, the requested procedure is not indicated in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept procedure
The insurer denied the Intracept procedure. 
The health plan's determination is upheld.

The patient is a female with a history of low back pain. The pain began over one year ago. Prior treatments have included home exercises, medications, physical therapy. She has trialed muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs). The pain impacts her activities of daily living (ADL). 

The proposed Nerve 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. Patient has complaints of low back pain.
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the Nerve 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept procedure
The insurer denied the Intracept procedure. 
The health plan's determination is upheld.

This is a female who has chronic low back pain. Her pain started about one year ago without any inciting injury. She described dull achy pain localized to the lower back with pain in the lateral aspect of the right leg down to the foot. 

The Intracept procedure was designed to treat low back pain from vertebral body. The available medical records did not reveal necessary evidence that vertebrogenic pain is her primary pain generator. This patient has low back pain with pain in right lateral thigh down to right foot. PE (physical exam) revealed Positive kemp Test and positive facet loading, which are indicative of facetogenic pain. She had positive Fortin finger test and positive sacral thrust and a right SI (sacroiliac) joint injection with 70% pain relief, which indicates SI joint is a significant pain generator. In addition, her lumbar spine the magnetic resonance imaging (MRI) revealed facet arthropathy at L (lumbar)3/4 L4/5 and L5/S (sacral)1, Moderate to large diffuse disc osteophyte complex with severe bilateral lateral recess and foraminal narrowing at L5/S1.
Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with clinical evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. Therefore, given this clinical scenario and current clinical studies, this patient is not an appropriate candidate for Intracept procedure, and the Intracept procedure is unlikely to be more beneficial than any standard treatment or treatments for the insured's medical condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Respiratory Insufficiency
Treatment: non-invasive home ventilator (NIV) (two mode)
The insurer denied: non-invasive home ventilator (NIV) (two mode)
The denial is: Overturned

The patient is a male with lissencephaly, seizure disorder, dysphagia, and other issues including chronic respiratory insufficiency and ventilator dependence. He has been using the Trilogy ventilator as a non-invasive ventilator in the average volume-assured pressure support (AVAPS mode), primarily for sleep but more frequently during the day as of late. The request for the continued coverage for the non-invasive (NIV) home ventilator (two mode) was denied by the health plan. The medical necessity for this is the subject under review.

The health plan's determination is overturned.

The requested service non-invasive home ventilator (two-mode NIV) is medically necessary for this patient.
The ventilator company did indeed provide records showing the patient is using the machine in the AVAPS-auto expiratory positive airway pressure (EPAP) AE mode during night hours. This documentation is sufficient. There are letters of medical necessity which do indeed state that the patient has failed bi-level positive airway pressure (Bi-PAP) therapy in the past.
There is a letter from the patient's neurologist, stating that his respiratory health directly affects the degree of his seizure control. This, together with the previously submitted documentation from the respiratory therapists detailing the much more sophisticated alarm system of the Trilogy versus standard BiPAP, which is important in the context of this non-verbal and noncommunicating patient at night, provide the most compelling argument in support of continuing the use of the existing ventilator. 
There are significant considerations to support its continuing use in the best interest of the patient. Specifically important are the more sophisticated alarm system, which makes it safer for this patient at night, and the fact that he has been stable on the current ventilator and changing it at this time can destabilize his respiratory status, leading to worsening seizure control and numerous complications down the road, including death.
This reviewer supports the medical necessity of the current ventilator for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (PCA) and Consumer Directed Personal Assistance Program (CDPAP) Services Increase to Total Amount of 50 Hours/Week: CDPAP 4 Hours/Day, 3 Days/Week plus (+) 6 Hours/Day, 2 Days/Week and PCA 6 Hours/Day, 3 Days/Week + 4 Hours/Day, 2 Days/Week
The insurer denied the PCA and CDPAP services increase to total amount of 50 hours/week: CDPAP 4 hours/day, 3 days/week + 6 hours/day, 2 days/week and PCA 6 hours/day, 3 days/week + 4 hours/day, 2 days/week.
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, obesity, low back pain, urinary incontinence, vertigo, and osteoarthritis who had been assigned CDPAP (Consumer Directed Personal Assistance Program) services as well as PCA (personal care aide) services.

The PCA and CDPAP services increase to total amount of 50 hours/week: CDPAP 4 hours/day, 3 days/week plus (+) 6 hours/day, 2 days/week and PCA 6 hours/day, 3 days/week + 4 hours/day, 2 days/week are medically necessary for this patient.

There is documentation from the patient's PCP (primary care provider) of medical necessity of increased CDPAP and PCA services. The plan's assessment documents a decline in activities of daily living (ADLs) status and deterioration of overall self-sufficiency in the last 90 days. Specifically, the patient's assistance needs with tasks of walking, locomotion, and transfer toilet increased to maximum assistance. The patient's previous tasking tool assessed 15 hours/week while the most recent assessments tasking tool calculated 45.5 hours/week which is essentially tripled previous hours. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when patient does not have informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS/PCA services total amount of 50 hours/week: CDPAP 4 hours/day, 3 days/week + 6 hours/day, 2 days/week and PCA 6 hours/day, 3 days/week + 4 hours/day, 2 days/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient is who was transferred from an outside hospital with abdominal pain. She had a computed tomography (CT) scan done that showed acute appendicitis. She underwent a single port appendectomy, at which time a nonperforated appendix was found. She recovered well and was discharged home the same day. On arrival to the emergency department (ED) she did receive morphine and intravenous fluids (IVF) as well as antibiotics. Her white blood cell count (WBC) was 16. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.

The patient presented with abdominal pain. A CT scan showed acute appendicitis. She underwent an appendectomy, at which time a non-perforated appendix was found.
A recent single center study of 180 pediatric patients demonstrated safety in same day discharge in simple appendicitis (1). The conclusion of this study is: Same-day discharge after laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way. This patient met the criteria for this treatment.

A second slightly older study found that there were no differences in outcomes for patients that had same day discharge for simple uncomplicated appendicitis. (2)
Conditional discharge orders and a nurse driven discharge pathway in simple appendicitis significantly decreases length of stay (LOS). (3)
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Tooth decay.
Treatment:  Root Canal and Crown to Teeth # (number) 9 and 23 with Deep Cleaning to All 4 Quadrants of Mouth and Partial Upper Denture.

The insurer denied Root Canal and Crown to Teeth # 9 and 23 with Deep Cleaning to All 4 Quadrants of Mouth and Partial Upper Denture.  The health plan's determination is overturned. 

The patient is a male who presents for evaluation and treatment of teeth #9 and 23 and deep cleaning for all four quadrants. 

Root Canal and Crown to Teeth # 9 and 23 with Deep Cleaning to All 4 Quadrants of Mouth and Partial Upper Denture are medically necessary for this patient.

Based on the provided documentation, the patient has decay entering into the pulp for teeth #9 and 23, which requires root canal therapy to remove the infection from the tooth and allow for continued use of the teeth. For the remainder of the mouth, there is ample evidence of bone loss and calculus on the root surfaces, which by definition means that the patient has attachment loss as well as active periodontal disease with the need for scaling and root planning. After root canal therapy the teeth will require posts in order to provide retention. Hence, the Root Canal and Crown to Teeth # 9 and 23 with Deep Cleaning to All 4 Quadrants of Mouth and Partial Upper Denture are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (status post laparoscopic appendectomy). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male. He presented with acute appendicitis. 

The patient was hemodynamically stable and had WBC (white blood count) of 12. CT (computed tomography) showed acute appendicitis. He was admitted and underwent lap appendectomy. There was no evidence of perforation, and he was discharged home the same day. 

The admission was denied coverage by the health plan on the basis of medical necessity for inpatient level of care, stating that this case could not have been managed at a lower level of care. The denial is being appealed. 

The Inpatient Hospital Admission was not medically necessary. 

The patient underwent uncomplicated appendectomy without evidence of perforation or sepsis. The patient was found to have uncomplicated acute appendicitis. The patient was admitted to inpatient and discharged the same day. The patient was tolerating a diet post operatively and did not have any intra-operative findings to suggest the need for ongoing IV (intravenous) antibiotics, IV (intravenous) fluids, or continued monitoring.  The patient's care could have been provided at a lower level of care rather than inpatient admission. Therefore, inpatient admission is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atrial fibrillation (AF)

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient presented to the hospital for elective catheter ablation of atrial fibrillation.  Past medical history was significant for persistent atrial fibrillation requiring DC (direct current) cardioversion and antiarrhythmic therapy with dofetilide. Additional relevant past medical history included hypertension, hyperlipidemia and gout.  He underwent an uncomplicated left atrial catheter ablation with successful pulmonary vein electrical isolation and was discharged the following day. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post-operative issues were noted.  

In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP (electrophysiology) study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1) Bartoletti demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) In a report involving over 6000 patients, same day discharge following catheter ablation of AF was found to be safe and comparable to outcomes in patients that were observed overnight. (Reference 3) 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Asthma

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This is a male child with a history of asthma who had been sick for 1 week with a cough, nasal discharge and post tussive vomiting. On the day of admission, he awoke from sleep with wheezing and increased work of breathing. His parents administered albuterol at home and when the increased work of breathing did not improve, they brought him to the ER (emergency room) for treatment.

In the ER he was noted to be in respiratory distress with increased work of breathing with accessory muscle retractions, grunting, and nasal flaring. On physical exam he was found to have diffuse coarse wheezing. His oxygen saturation was 87% on room air. He was treated with albuterol, duoneb, decadon and magnesium sulfate. When his oxygen saturation continued to be low at 92%, he was started on 20 liters of oxygen by high flow nasal canula and continuous albuterol for 2 hours. A respiratory viral panel was positive for rhino and enterovirus. Following treatment in the ER, the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with oxygen and albuterol every 2 hours

The child was treated appropriately in the ER for an acute episode of wheezing, hypoxemia and difficulty breathing. The child has a history of previous admissions for asthma, but he was not compliant with prescribed budesonide to control his asthma. In addition, the child had not been taken to a scheduled appointment with a pediatric pulmonologist. When he did not respond to treatment in the ER, and he was noted to have persistent hypoxemia and increased work of breathing it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with oxygen and albuterol every two hours. He was not stable enough to be safely discharged. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine bleeding, fibroid uterus
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female with abnormal uterine bleeding, heavy menses, fibroid uterus, pelvic pain, and endometriosis.  She is a smoker.  Symptoms are not controlled with progesterone only hormones.  The patient had a prior open myomectomy 6 years ago. 

The patient's exam revealed a 14-16 week size uterus which was enlarged from 10-12 weeks a few years earlier.  Ultrasound confirmed multiple fibroids.  The patient was counseled about options.  She underwent an abdominal supracervical hysterectomy and bilateral salpingectomy.  The procedure was not complicated.  The patient had some anemia postoperatively where her hemoglobin when from 12.4 to 10.5.  She had stable vital signs without signs of hypotension or tachycardia.  Her post operative course was unremarkable.  The patient was given Toradol and intravenous morphine as needed for pain.  On post operative day # (number) 1, the patient was tolerating a diet, her Foley had been removed and she was voiding on her own.  The patient was ambulating, passing flatus and her pain was controlled.  She was discharged home with follow up.

The proposed inpatient hospital admission was not necessary.

In review of the medical record, the patient underwent an abdominal supracervical hysterectomy with bilateral salpingectomy for an enlarged fibroid uterus causing heavy menstrual bleeding.  The procedure was uncomplicated with expected blood loss.  Post operatively, the patient was in the recovery room with stable vital signs.  She was transferred to the floor and given Toradol and Tylenol for pain.  She had morphine ordered as well but she did not use this.  The patient remained hemodynamically stable with no bleeding, no severe pain, and normal urine output.  Her diet was advanced and the catheter was removed the next day.  

In addition, under the two-midnight rule established by the Centers for Medicare and Medicaid Services (CMS) in 2013, hospital inpatient admissions are considered reasonable and necessary for patients whose stays cross two midnights. (AMA, 2016)  

Therefore, the care provided did not require an inpatient hospital stay.  The same care could have been provided at a lower level of care yet still provided the same outcome.