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

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation
The insurer denied Intraosseous Basivertebral Nerve Ablation
The health plan's determination is upheld. 

This patient is a female with a significant medical history of hypertension and gastric reflux who has chronic neck pain, low back pain and lower extremity pain. The patient had previously underwent cervical spinal injections with improvement of her neck pain. Her lower back pain is in the center of back with radiation to bilateral anterior lateral and posterior thighs. Her pain is burning and tingling. 

Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Intraosseous Basivertebral Nerve Ablation was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has low back pain with radicular pain down to both lower extremities. She responded to a prior lumbar epidural steroid injection. MRI showed a disc bulge and bilateral facet arthropathy with mild bilateral foraminal narrowing at L (limbar) 4-5 level, and a central disc herniation with superimposed disc bulge approximating bilateral S1 nerve roots with facet arthropathy contributing to bilateral foraminal narrowing at L5-S (sacral) 1. Current studies including Truumees's supported the efficacy of Intracept procedure for vertebrogenic pain. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded from these studies.
Given this patient's radicular symptoms, MRI (magnetic resonance imaging) findings of L4/5 and L5/S1 disc bulge with facet arthropathy, and the exclusion criteria of current clinical studies, the requested procedure is not likely to be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: shortness of breath
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female with a medical history of hypertension, diabetes mellitus, peripheral vascular disease, chronic kidney disease stage 3, obstructive sleep apnea, history of stroke, and chronic obstructive pulmonary disease (COPD) who was admitted for an acute COPD exacerbation with symptoms of shortness of breath that began the day prior to admission She was treated with Duoneb nebulizers, magnesium sulfate and Solumedrol with an improvement in her condition within 24-hours. 

Based upon the severity of illness and intensity of required therapy provided, the inpatient hospitalization was not medically necessary. This patient was admitted for an acute COPD exacerbation with symptoms of shortness of breath that began the day prior to admission. On admission, the patient was afebrile, hemodynamically stable, had a respiratory rate of 18 breaths per minute, an oxygen saturation of 98% on room air. She was not in any respiratory distress, had a normal pulmonary effort and normal breath sounds on auscultation of the chest. Her chest x-ray did not demonstrate evidence of an empyema/abscess/pneumonia/pleural effusion. She was treated with Duoneb nebulizers, magnesium sulfate and Solumedrol. Throughout the hospitalization, she was alert, awake and oriented, and did not have evidence on arterial blood gas for hypercapnia or hypoxemia. She had no reported cyanosis or increased work of breathing after observation, and she did not have any cardiac dysrhythmias. Therefore, the Inpatient Hospital Admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: jaw pain/swelling
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with left jaw swelling and pain. He visited the dentist and was placed on antibiotics which relieved the pain and swelling. Subsequently, the pain and swelling returned. The patient was afebrile and the WBC's (white blood cells) were elevated at 15.41. The airway was clear. He was treated with an incision and drainage and removal of tooth number (#) 20 and admitted for intravenous (IV) antibiotics. The patient was discharged the following day.

The inpatient hospital stay was not medically necessary for this patient.
Patients presenting with signs of sepsis, facial swelling, trismus (limited mouth opening), or dysphagia should be reviewed by a dental or maxillofacial surgeon without delay for appropriate surgical and medical management. Prompt assessment and referral to a tertiary hospital is required for cases at risk of airway compromise. Treatment involves draining the abscess, providing antibiotic support, pain control and removal of infectious tooth source. Often, oral antibiotics with timely dentist appointment for dental caries intervention is sufficient. Dental abscesses may not require an admission to the hospital and administration of intravenous (IV) antibiotics unless the patient presents with worrisome features that include fever, dyspnea or airway compromise secondary to swelling. This patient had a need for IV antibiotics but no airway compromise and was not afebrile, however, this could have been administered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Customer Directed Personal Assistance Services (CDPAS) for 56 hours/week 
The insurer denied CDPAS for 56 hours/week.
The determination is overturned.

This is a female patient with a medical history notable for dementia. The patient was previously approved for 56 hours/week of consumer directed personal assistance services CDPAS). The plan reduced the patient's weekly hours to 49 hours/week.

A community advocate provided a letter of support for this appeal. The patient lives by herself and has progressive dementia. The plan has offered her a Personal Emergency Response System (PERS), but the patient is unable to use it due to her cognitive condition. She has urinary and fecal incontinence and cannot change her diaper. She is not able to ambulate without assistance.

The patient's physician assistant provided a letter of support for this appeal. The patient has dementia, reduced mobility, arthritis, atrial fibrillation, coronary artery disease (CAD), and osteoporosis. She is unable to walk independently without human assistance. She had a fall with a hip fracture. She wears diapers for urinary and fecal incontinence and requires multiple daytime and nighttime changes. The provider recommends at least 12 hours/day of personal care assistance (PCA).

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person at the patient's apartment. The patient was alert and oriented to person and place only. She was able to make her needs known but required assistance with complex decisions. For her instrumental activities of daily living (IADLs), the patient requires total dependence for housework, transportation, and stairs. She requires maximal assistance for shopping, finances, and meal preparation. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is frequently incontinent of urine and infrequently incontinent of stool. Compared to a prior assessment, the patient showed a similar level of function. At issue is the medical necessity of CDPAS for 56 hours/week.

The requested health service of CDPAS for 56 hours/week is medically necessary for this patient.

The patient has severely limited mobility as outlined in the assessment. She requires caregiver assistance to complete all ADLs, including transfers, ambulation, and toileting. Her functional status is further limited by her dementia and limited ability to direct her own care. Her care needs can be expected to be continuous on schedule throughout the day. The modest requested increase is medically necessary and reasonable for the patient. Failure to address the patient's personal care needs could result in infection, skin breakdown, and/or injury.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult male with a past medical history of diabetes, depression, and hyperlipidemia. He presented to the hospital with report of left facial swelling and scattered areas of fluid filled blisters on his arms, as well as rashes on his legs. He also endorsed a headache and sore throat. The patient's initial vital signs showed a pulse of 121, blood pressure 127/89, respirations 18, temperature 97.5, and oxygen saturation 97%. His physical exam was notable for left-sided facial swelling with fluid filled blisters, honeycomb home crusted lesions on the left side of his face, and multiple fluid filled blisters to his hands and arms. Labs were sent which showed a grossly normal complete blood count, glucose 141, sodium 133, whole blood potassium 5.4, and C-reactive protein (CRP) 87.61. A computed tomography of the sinuses with contrast was performed that showed premaxillary soft tissue and preseptal cellulitis, with no evidence of sinusitis and with no septal involvement. The patient was given Tylenol, Benadryl, Pepcid, prednisone, intravenous fluids, and intravenous ceftriaxone. The patient was subsequently admitted for further evaluation and treatment. During the patient's hospitalization, dermatology was consulted for further evaluation and management, and they recommended escalation of antibiotic coverage as well as ophthalmology consultation due to findings of preseptal cellulitis. He was continued on intravenous ceftriaxone and doxycycline, and he was also started on intravenous vancomycin, and received additional doses of Benadryl. The patient was evaluated by ophthalmology and dermatology. The patient continued to improve and was discharged on oral antibiotics.

The inpatient admission was medically necessary.

The patient presented with sudden onset of blisters and cellulitis involving the left face. Computed tomography (CT) of the sinus showed extensive soft tissue infiltration involving left-sided premalar and preseptal soft tissue. The patient was evaluated by dermatology and ophthalmology and advised to continue on intravenous antibiotics. In view of the rapidity of development of cellulitis and the severity of presentation and the fact that the cellulitis involved the area near the eye, continued intravenous antibiotics was medically needed. In addition, inpatient monitoring of the patient was needed to ensure that the patient continued to improve on the treatment given and to make adjustments needed if the patient was not improving as expected. Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lymphedema
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female. She has been advised to undergo suction-assisted lipectomy for lymphedema (SAPL). The issue under review is whether inpatient hospital stay is required after the procedure. The request for inpatient stay was denied coverage by the health plan on the basis that the surgery can be done on an outpatient basis. The denial is being appealed.

The inpatient admission is medically necessary.

This adult patient has been followed for right leg stage 2 solid-predominant lymphedema. She has undergone an intensive conservative regimen that involves compression wrapping, stockings, elevation, and manual lymphatic drainage. Because of failure of this approach, her provider has recommended suction assisted lipectomy for lymphedema, sometimes referred to as suction assisted protein lipectomy (SAPL). The provider has requested approval for inpatient hospital stay following the procedure, but coverage for inpatient stay has been denied on the basis that it is unknown whether the patient will have medical problems requiring inpatient hospital stay. Suction assisted protein lipectomy surgery is performed under general anesthesia and involves removal of 1500 to 2000 milliliters of tissue from the affected extremity. Because of the large volume of aspiration, the patient can experience significant redistribution of volume and/or blood loss. It is widely accepted that patients require inpatient hospital stay, usually two to three days, after the procedure (1-3). The purpose of inpatient stay is hemodynamic monitoring, fluid resuscitation, and pain control. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: rheumatoid arthritis (RA)
Treatment: Rinvoq
The insurer denied Rinvoq
The health plan's determination is upheld. 

The patient is a male with rheumatoid arthritis (RA). Rinvoq is being requested and was denied by the health plan. Per a letter from the patient's provider, the patient has a phobia of needles, thus he is not 'comfortable' with injectable medications. He has only tried nonsteroidal anti-inflammatory drugs (NSAIDs).

Rinvoq is not medically necessary at this time. There is no medical reason the patient cannot try one of the formulary medications, which are all indicated for the treatment of RA.
There are myriad options available, including disease modifying anti-rheumatic drugs (DMARDs) and biologics. The reason for not trying a tumor necrosis factor (TNF) inhibitor per the patient's provider is a phobia of needles; however, some TNF inhibitors are given via infusion and while the others are given via injection, there is no reason why a family member/friend/care give cannot administer the injection, or the patient cannot learn to inject himself with teaching. There is also no reason he cannot try methotrexate (MTX). Per the records, he is concerned about hair loss but this is usually overcome by taking a folic acid supplement along with MTX. As per UpToDate, 'we suggest MTX as the DMARD of choice for the initial treatment of patients with active RA. MTX typically serves as the "anchor" drug for the most commonly used DMARD combinations'. Moreover, UpToDate then suggests adding a TNF inhibitor if the patient fails MTX monotherapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity weakness, numbness
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The determination is upheld.

The patient is a female with a history of obesity status/post (s/p) gastric bypass, who presented to the emergency department (ED) for lower extremity (LE) weakness and numbness for several weeks' duration. On review of systems, there was groin pain as well.

The patient was afebrile and not in acute distress. The physical examination was unremarkable for positive findings. Laboratory evaluation demonstrated unremarkable clinical findings.

The patient was admitted for lumbar radiculopathy. Magnetic resonance imaging (MRI) of the spine showed disc protrusion of thoracic (T) 7-8, lumbar (L) 5-sacral (S) 1 bulge. MRI of the brain was unremarkable. The patient was treated with Tylenol and intravenous (IV) fluids. At issue is the medical necessity of an inpatient level of care.

The requested health service/treatment of inpatient hospital admission was not medically necessary.

The patient was admitted for thoracic/lumbar radiculopathy in the setting of disc bulges. The documentation does not support inpatient admission since the patient had stable hemodynamics, no evidence of fracture or acute new findings that required urgent/emergent surgical intervention.

Lumbar radiculopathy describes pain in one or both lower extremities, often in the setting of back pain, secondary to compression or irritation of nerve roots in the thoracic/lumbar spine. Most cases of lumbar radiculopathy will resolve regardless of the type of treatment. Nonoperative treatment includes physical therapy involving strengthening, stretching, and potentially traction, as well as nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage. In patients with red flag symptoms or persistent symptoms after four to six weeks of treatment, MRI and further interventions may be warranted. In this case, the patient had an MRI done and did not have any acute or significant findings such as cord compression or cauda equina syndrome. The patient did not have acute focal neurologic deficits. A lower level of care would have been the most appropriate for pain control and imaging/workup.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	 Kidney stone	

Treatment:  Cystoscopy and stent placement

The insurer denied inpatient stay.  The denial is upheld.

This patient presented to the Emergency Department (ED) complaining of 3 days of worsening left sided abdominal and flank pain. Past medical history included hyperlipidemia. The patient was afebrile with stable vitals in ED. White blood count (WBC) 11,800. Computed tomography (CT) scan revealed an 8-millimeter (mm) obstructing left ureteropelvic junction (UPJ) stone with mild left hydronephrosis. The patient was given intravenous (IV) fluids, IV pain meds, and was admitted. The patient was seen by Urology, was taken to the operating room for cystoscopy, left retrograde study and left stent placement. The patient tolerated the procedure well, had postoperative stent pain, managed with diazepam, and Flomax. The patient was deemed stable for discharge two days later with outpatient follow up. 

The insurer has denied coverage for the full hospital admission as not medically necessary, they noted a lack of severe medical issues or complications warranting a full hospital admission. The appeal on behalf of the hospital is noted and read in detail.

Per Milliman Care Guidelines (MCG) Health:

i.	Renal Colic + Kidney Stones Guidelines - Patient fails to meet indications for hospital admission
ii.	Urologic Surgery or Procedure General Recovery Guidelines - Patient meets the General Recovery Criteria discharge parameters within 24 hours post procedure

Full hospital admission is not considered medically necessary for this patient. This procedure is performed in the ambulatory surgery 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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned



 
Diagnosis: Urinary Tract Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult with a past medical history significant for hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, and rheumatoid arthritis. The patient presented to the emergency room (ER) with complaints of fever, chills, abdominal pain, and upper back pain.

Vitals on presentation included a temperature of 101 Fahrenheit (F), blood pressure (BP) of 121/80, pulse of 100, a respiratory rate (RR) of 20 breaths per minute, and an oxygen (O2) saturation of 97% on room air.

Laboratory results included a white blood cell (WBC) count 9.8, hemoglobin (Hgb) 10.0, hematocrit (Hct) 29.9, procalcitonin 0.07, creatinine 1.08, glucose 188, and lactate 0.8.

The patient was started on intravenous (IV) fluids and empiric antibiotics (ceftriaxone and meropenem) for a possible urinary tract infection (UTI). Urine cultures grew Enterococcus faecium susceptible to vancomycin. Infectious Diseases consulted and recommended continuation of ceftriaxone, as well as a Doppler of the upper extremity. Testing was initially negative for deep vein thrombosis (DVT). Repeat testing showed right axillary and subclavian DVT. Anti-coagulation was initiated. The patient remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management.

According to the documentation, the patient presented with fever of unclear etiology. The patient was recently treated for a extended-spectrum beta-lactamase (ESBL) urinary tract infection. The patient had a fever (101. F) and tachycardia. The hospital work-up showed an acute right upper extremity DVT. Based on the complexity of presentation in a high-risk immunocompromised patient with history of rheumatoid arthritis and previous ESBL infection, the hospital admission was medically necessary.   

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

Diagnosis: Benign prostatic hyperplasia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult male patient with a history of symptomatic benign prostatic hyperplasia and hyperlipidemia. He underwent robotic-assisted simple prostatectomy. The procedure was without complications and no anesthesia problems. Preoperative hematocrit was 47.4. Estimated blood loss was 200 milliliters (mL) (anesthesia note) to 300 milliliters (operative report). The patient was hemodynamically stable. Repeat hematocrit was 46.3. The patient was admitted for inpatient admission. The patient experienced no complications or events overnight. Repeat hematocrit was 43.3. The patient was discharged to home the next day. The discharge note indicates he was without postoperative events or complications. Service was denied as the patient did not meet criteria for inpatient admission including disease or condition like an active infection, bleeding disorder, dangerous heart rhythm or unstable blood pressure, complex surgery that required longer recovery after surgery than expected, or severe complication from procedure.

The requested health service was not medically necessary.

This patient has no major medical comorbidities. He underwent an uncomplicated surgery. He remained hemodynamically stable during and after the surgery. He had no anesthesia adverse events. His hematocrit remained stable. There were no adverse events or complications during the course of his hospitalization. The patient could have been cared for at a lower level of care. Therefore, the requested health service was not medically necessary.