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

Diagnosis: Lower extremity weakness
Treatment: Continued alternate level of care rehab
The insurer denied coverage for continued alternate level of care rehab
The denial is upheld

According to the medical records, this is an adult male with a history of diabetes, hypertension, chronic embolism, hyperlipidemia, anemia, metabolic encephalopathy, gastrointestinal (GI) hemorrhage, and chronic kidney disease (CKD). He presented to the rehabilitation facility after being hospitalized. He is alert and oriented x 3. He is participating with therapy and is mostly supervised. He does need moderate assist for stairs. He is modified independent for bed mobility.

"Skilled nursing facility (SNF) care is health care given when you need skilled nursing or therapy staff to treat, manage, observe, and evaluate your care. Examples of SNF care include intravenous injections and physical therapy. Care that can be given by non-professional staff isn't considered skilled care. People don't usually stay in a SNF until they're completely recovered because Medicare only covers certain SNF care services that are needed daily on a short-term basis (up to 100 days in a benefit period). Skilled care is nursing and therapy care that's so complex it can be safely and effectively performed only by, or under the supervision of, skilled nursing and therapy professionals. Skilled nursing and therapy professionals include:

-	Registered nurses
-	Licensed practical and vocational nurses
-	Physical and occupational therapists
-	Speech-language pathologists
-	Audiologists" (Centers for Medicare and Medicaid Services (CMS) (2015)

Records do not indicate that there are significant or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing medication management, skin care, labs and vital signs monitoring, and daily therapy can be provided at a lesser level of care. A lesser level of care would have adequately provided care.

Therefore, the health plan acted reasonably, and with sound medical judgement and in the best interest of the patient. The continued alternate level of care is considered not medically necessary for this patient.

The insurer's denial of coverage for a continued alternate level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cerebrovascular accident (CVA)
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is overturned.

The patient is a male who presented to the Emergency Department (ED) for speech changes and facial asymmetry. He had multiple vascular risk factors, including diabetes mellitus, hypertension, and hyperlipidemia. In the ED, he was noted to have slurred speech, left sided facial droop with forehead sparing. His National Institutes of Health Stroke Scale (NIHSS) was 3. Head computed tomography (CT) showed new acute infarct in the right internal capsule posterior limb. Computed tomography angiography (CTA) Head and Neck showed severe stenosis at the origin of left vertebral artery. He was admitted to inpatient level of care for acute cerebrovascular accident (CVA).

Given that the patient had persistent new focal neurological deficits in the ED in the context of multiple vascular risk factors as well as head CT showing acute CVA, inpatient admission was medically necessary and consistent with current standards of medical practice. 

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 full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fractured tooth.
Treatment:  Crown (Tooth # [number] 29).

The insurer denied Crown (Tooth # 29).  The denial is upheld.

The case is a request to review the medical necessity of a dental crown on tooth #29 of an adult male patient. The patient had presented to the provider with an amalgam restoration on the tooth and sensitivity. It was diagnosed as a fractured tooth, and the decision was made to crown it.

The request for coverage was denied previously on the basis of a lack of medical necessity because extensive tooth structural loss or fracture was not demonstrated.

The proposed crown on tooth #29 is not medically necessary.

The case is a request to review the medical necessity of a dental crown on tooth #29 of an adult male patient. The request for coverage was denied previously on the basis of a lack of medical necessity because extensive tooth structural loss or fracture was not demonstrated. 

The patient had an amalgam restoration on the tooth and sensitivity. It was diagnosed as a fractured tooth, and the decision was made to crown it. No alternative treatments are documented as having been discussed. No clinical notes of the procedure are submitted documenting findings during the restoration, such as a noted fracture. No radiographic evidence of fracture is appreciated on the panoramic film. No periapical films are submitted. No pulp testing findings are noted.  This lack of clinical detail fails to substantiate the medical necessity of the procedure, and the denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male who presented to the emergency department with concerns of alcohol withdrawal. Pertinent history included severe alcohol withdrawal requiring Intensive Care Unit (ICU) care, alcohol use disorder, and asthma. Initial vital signs revealed a temperature of 98.9oF, heart rate (HR) 100, blood pressure (BP) 125/91, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 95% on room air. Initial examination documented a visible tremor, tongue fasciculations, and mild diaphoresis. Clinical Institute Withdrawal Assessment (CIWA) score was 12. 

The inpatient hospital admission was medically necessary. 
The patient had a history of alcohol abuse and alcohol withdrawal and presented with alcohol withdrawal. Initial evaluation revealed a gross tremor, tongue fasciculations, anxiety, diaphoresis, and tachycardia. CIWA was recorded at 12 and benzodiazepines were provided. Treatment included continue CIWA and the following morning the patient had a CIWA > 8 requiring additional benzodiazepine administration. Psychiatry consultation was obtained for concerns of underlying moderate depression contributing to the overall clinical situation. Ultimately, the patient was discharged with plans to enter an inpatient rehabilitation program. Clinical indications for admission to inpatient care were met. The patient had high-risk features including a history of withdrawal syndromes requiring ICU level of care. In addition, the patient did have an alcohol withdrawal syndrome that is not manageable at lower level of care such as marked signs of withdrawal plus inadequate response to pharmacotherapy in emergency department or other appropriate lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute appendicitis
Treatment: Inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is overturned.

The patient presented with right lower quadrant (RLQ) abdominal pain. He was afebrile and the vital signs were stable. RLQ abdominal tenderness was present but there was no abdominal rebound or guarding. The white blood cell count (WBC) count was 10.5. A computerized tomography (CT) scan was consistent with acute appendicitis. He was positive for COVID-19 (coronavirus disease 2019). Intravenous (IV) antibiotics were given for 1 day, after which he was much improved and was discharged on oral antibiotics. 

MCG (Milliman Care Guidelines) for Gastroenterology MG-GAS lists clinical indication for admission for inpatient care. Acute appendicitis with planned nonoperative management is an indication for admission under certain conditions. This would be the case, if doing an appendectomy is not the preferred treatment for uncomplicated appendicitis or if there is a prohibitive surgical risk. 

This patient was diagnosed with acute appendicitis based on the physical exam and CT scan evidence of acute appendicitis. It was felt that due to his COVID-19 status, surgery was not the preferred treatment and that he should be treated with IV (intravenous) antibiotics. He improved rapidly on the IV antibiotics. However, in view of the diagnosis of acute appendicitis and the decision that surgery was not the preferred method of treatment but that he should receive IV antibiotics, he has met the MCG criteria for admission for appendicitis under Gastroenterology MG-GAS. 

Based on the above, the insurer's denial must be overturned. 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 inpatient facility services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral vascular disease, unspecified
Treatment: Ambulatory surgery (75630x [times] 1, 37220x1, 37221x1 and 37224x1)
The insurer denied ambulatory surgery (75630x1, 37220x1, 37221x1 and 37224x1).
The denial is upheld.

The patient is an adult male who reportedly has leg cramping symptoms. Noninvasive testing suggests the possibility of left superficial femoral artery (SFA) stenosis. Ankle brachial index (ABI) is diminished bilaterally (left 0.7; right 0.85). The provider has recommended left leg angiogram and possible intervention. Coverage was denied on the basis that the patient has not had a trial of conservative therapy.

The proposed treatment is not medically necessary.

This patient presented with leg cramping. However, the available history of his condition is grossly inadequate. The initial office note does not give a history at all. It merely states in the impression section that the patient has claudication. A revised version of this same office note states that the patient has lifestyle limiting claudication and that the patient has failed five months of conservative therapy. However, this information does not constitute an adequate history of the present illness. The patient's symptoms are not described in sufficient detail to delineate whether they are due to vascular insufficiency or some other etiology. Moreover, the conservative therapy is not described at all.

Conservative management for claudication is a crucial aspect of proper care, before intervention is considered. A proper regimen includes appropriate medications (aspirin and statin), counseling on smoking cessation, a walking program (ideally with supervision), and, in some cases, cilostazol. The available record does not reflect any elements of this regimen.

Intervention should not be considered for claudication without clear documentation that the symptom is lifestyle limiting. A determination of lifestyle limitation can only be made after obtaining a complete history from the patient. No such documentation is available in the current record.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain
Treatment: Intraosseous basivertebral nerve ablation procedure
The insurer denied coverage for intraosseous basivertebral nerve ablation procedure. 
The denial is upheld. 

This is the case of an adult female with a history of chronic low back pain, right shoulder pain, osteopenia, and anxiety. The patient was seen by Pain Medicine Specialist for chronic low back pain. A physical exam showed decreased range of motion (ROM) and pain with extension and facet loading. Diagnostic imaging revealed minimal levoscoliosis in the lower thoracic and lumbar spine, grade 2 anterolisthesis at lumbar (L) 4-5, spondylosis and facet arthrosis, moderate-to-severe central stenosis at L4-5 and left-sided disc protrusion at L5-sacral (S)1 impinging on the left S1 nerve root. The patient has completed multiple rounds of physical therapy (PT), a home exercise program, and lumbar facet radiofrequency ablation (RFA) injections. Pain is reported to impede the patient's quality of life and activities of daily living (ADL). 

The scientific evidence in peer-reviewed literature is insufficient to determine if the technology supports a result of in an improvement in health outcomes. The publications to date have been mostly company-sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. The Spine Society makes no mention of the Intracept procedure or ablation of the basivertebral nerve using radiofrequency. 

For individuals who have vertebrogenic low back pain who receive ablation of basivertebral nerves, the evidence includes two randomized controlled trials (RCTs): Smart and Intracept trials, both sponsored by device manufacturer Relievant Medsystems, Inc. Relevant outcomes were symptoms, functional outcomes, quality of life and treatment-related morbidity. In one RCT, at 12 months, 73% (percent) of patients crossed over to the active treatment group and therefore long-term comparative data is not available. Limitations to the other RCT include lack of a sham control and short duration of follow-up. 

Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments. Furthermore, with clinical evidence of lumbar spondylolisthesis and symptomatic spinal stenosis, this patient would have been excluded from the Intracept trial and therefore the Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient. Therefore, based on this evidence, this patient is not a good candidate for intraosseous basivertebral nerve ablation procedure with the Intracept device. There are other evidence-based medications and treatments available to this patient. 

In summary, the denial of intraosseous basivertebral nerve ablation procedure 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 risks may be increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure, Alcohol withdrawal
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a patient with a history of human immunodeficiency virus (HIV), hypertension (HTN), alcohol use disorder, and cerebrovascular accident (CVA) with residual deficits who presented to the emergency room (ER) after suffering a seizure at home. He was noted to be confused and postictal. He mentioned he was in alcohol withdrawal. In the emergency department (ED), his Clinical Institute Withdrawal Assessment (CIWA) score was 16 and so he was started on intravenous fluids (IVF), thiamine, magnesium, intravenous (IV) Ativan, Keppra and was subsequently admitted. 

He was admitted with the diagnoses of alcohol withdrawal and was started on a CIWA protocol; transaminitis-likely due to alcoholic hepatitis, seizures-on Keppra at home, unknown if seizures were related to alcohol, hypomagnesemia-repleted. Other chronic problems included HIV, HTN, and a history of a CVA for which his medications were continued.

He was noted to have tremors but was alert and oriented times (x) 3.

The CIWA protocol was continued, Consult for Addiction Treatment and Care in Hospitals (CATCH) consult was made, physical therapy (PT) consulted, Keppra and the rest of the medications were continued. 

A physical therapy (PT) review was pending for gait assessment, otherwise was stable. He had been seen earlier by Addiction Medicine; he had been seen in the past but was lost to follow up. On exam, his vital signs were stable, he was noted to be cooperative but somewhat confused, oriented to person and place, the rest of the exam was stable. The plan was for the patient to receive intramuscular (IM) vivitrol prior to discharge with arrangements to be made for outpatient follow up.

He was deemed stable for discharge and was subsequently discharged home.

At issue is the medical necessity of an inpatient hospital stay.

The inpatient hospital stay was medically necessary.

Based on a review of the provided records, the patient presented to the ER after suffering a seizure and was noted to be postictal. It was also noted that he was in alcohol withdrawal. He had a history of prior admissions for alcohol withdrawal, comorbid illnesses of HTN, CVA, HIV with noted poor compliance. In the ED, he was hypertensive and tachycardic, had elevated an lactic acid and elevated anion gap (AG) with low magnesium and also had a high CIWA score of 16.

As a result of his seizures which could be either due to poor compliance in a patient with known seizure or due to alcohol withdrawal, high CIWA score, electrolyte abnormality, comorbid illness of CVA, he was at a high risk for clinical morbidity. As a result, admission at an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain.
Treatment: CT of the abdomen and pelvis and the low osmolar contrast material.
The insurer denied CT of the abdomen and pelvis and the low osmolar contrast material.
The determination is overturned.

The patient presented with persistent epigastric abdominal pain and bloating; a proton pump inhibitor had been ineffective. An ultrasound of the abdomen was unremarkable other than a 2 centimeter (cm) hemangioma in the right liver lobe. Testing showed a normal lipase and celiac disease labs and lack of ova, parasites, and Giardia. The computed tomography scan of the abdomen and pelvis showed mild pancolitis, a 1.9 centimeter (cm) hepatic hemangioma, and a 5 millimeter (mm) nodular opacity in the right lower lobe of the lung. At issue is the medical necessity of the requested computed tomography scan of the abdomen and pelvis.

Yes, the requested computed tomography scan of the abdomen and pelvis with intravenous contrast is medically necessary. 
This patient had ongoing epigastric abdominal pain without findings to explain the symptoms on ultrasound or response to proton pump inhibitor therapy. A computed tomography (CT) scan is beneficial in diagnosing adult patients with abdominal pain and is considered the first-line imaging modality for this indication in this population [1]. It is broadly used in clinical practice for the evaluation of abdominal pain. There are a number of medical diseases with nonspecific symptoms which cannot be diagnosed using physical examination alone. One example is adult intussusception, which presents with non-specific abdominal pain; CT is the most sensitive diagnostic method for diagnosis [2,3]. CT has become a primary imaging test for evaluation of the small bowel and is especially useful in diagnosis of Crohn's disease; it is also effective in diagnosis of the extra-enteric manifestations of the disease, including fistulae, sinus tracts, and abscesses [4]. CT is the imaging test of choice for the diagnosis of vascular compression syndromes, such as median arcuate ligament syndrome, which may present with abdominal pain and nonspecific and obscure symptoms, causing delayed or erroneous diagnoses [5]. An internal hernia may also present with abdominal pain, and may result in small bowel obstruction, or strangulation with infarction [6]. Upper endoscopy can be useful for the diagnosis of gastroesophageal reflux disease and inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease), but these were not identified as causes for the patient's symptoms [7]. Given that a cause for ongoing abdominal pain had not been definitively determined in the patient at the time of the scan, and that CT scan has a high sensitivity for several serious etiologies for abdominal pain that cannot be discovered by physical examination or more limited imaging examinations, and given that the patient has a history of abdominal pain without finding on ultrasound or response to proton pump inhibitor therapy, the CT scan should be considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Left leg and Groin Swelling.
Treatment: Inpatient Admission.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with no past medical history (PMH) who was admitted with complaints of worsening left leg swelling. Vital signs were unremarkable. Physical exam was notable for no apparent distress (NAD), left lower extremity (LLE) with diffuse edema from thigh to the lower leg. Lab work was unremarkable. Imaging studies included a venous doppler which showed occlusive acute thrombus within the left iliac vein extending to the common femoral bifurcation, a computed tomography (CT) which showed malignant-appearing lymph nodes compressing venous structures. The patient was diagnosed with acute LLE deep vein thrombosis (DVT) and was treated with full-dose anticoagulation, expert consultation, and a hypercoagulability work-up. The patient was discharged in stable condition.
What is at issue is the medical necessity for the inpatient level of care.

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

Yes, the hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of worsening LLE swelling. The patient was found to have an acutely occlusive and extensive DVT extending into the common femoral bifurcation associated with malignant-appearing lymph nodes compressing venous structures. This patient was at risk of severe complications including pulmonary embolism and cardiorespiratory deterioration, as well as bleeding from full-dose anticoagulation. In addition, the patient required clinical monitoring for bleeding, worsening compression of venous structures, severe pain related to DVT, and expert consultations for evaluation of need for invasive procedures. Overall, this patient with advanced cancer and extensive DVT could not have been safely monitored and treated at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer - Testicular Cancer.
Treatment: Radiology Services - Chest CT Scan.
The health plan denied the chest CT scan as not medically necessary. 
The health plan's determination is upheld in whole.

The patient is a male with a history of stage I nonseminoma of his left testicle status/post (s/p) orchiectomy. He was recommended to proceed with surveillance imaging. A request was made for retrospective approval of a computed tomography (CT) scan of his chest.
At issue is the medical necessity of the requested service/treatment of Radiology-Oncology services-CT scan.
The health plan's determination of medical necessity is upheld in whole.
The requested surveillance chest CT scan is not medically necessary for this patient. Surveillance with a chest CT scan (as opposed to chest x-ray or plain film) is not proven to yield superior clinical outcomes. A surveillance chest CT scan for stage I nonseminoma is not supported by the National Comprehensive Cancer Network (NCCN) guideline. A chest CT scan for routine surveillance of testicular cancer is not supported by any expert consensus guideline. The records do not show that the patient was exhibiting signs/symptoms suggestive of recurrence, nor were there equivocal findings on prior imaging studies that would have warranted a more intensive follow-up imaging procedure to be performed. Therefore, the requested CT scan was not medically necessary for this patient.