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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All). 

The insurer denied Intracept Procedure. 
The denial was overturned.

This patient is a male who has a long history of low back pain and neck pain. His low back pain is dull and achy, localized in the lower back with no radiating pain in the legs. His pain level is 7/10 and above with significant functional limitation and diminished quality of life. He failed conservative treatment including pain medications and physical therapy (PT). His physical examination (PE) showed limited range of motion (ROM) with positive Kemp's test. The magnetic resonance imaging (MRI) scan revealed multilevel generative disc disease with Modic changes at lumbar (L)5 sacral (S)1. This patient was recommended to have an Intracept procedure at L5 and S1.
At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment for the patient's condition.

The health plan's determination regarding the proposed health service or treatment is overturned in whole.

The proposed health service or treatment Intracept procedure is likely to be more beneficial than any standard treatments for the patient's medical condition.
The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrating the efficacy of this intervention. This patient has persistent back pain consistent with L5-S1 end plate degenerative changes. He had failed conservative treatments including pain medications and PT. His pain is severe with significant functional impairment. Further interventions are medically necessary to improve his pain and functional level. Other potential treatment options are long-term use of medications (Non-steroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery, but none of these options has a high success rate, and all of them carry more risks and complications. Given this clinical scenario, Intracept is the appropriate next step intervention.
Therefore, the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Back Pain
Treatment: Pain management

The insurer denied coverage for pain management.
The denial is upheld.

This woman has arthritis, hypertension, osteoporosis, lower back pain and right-side sciatica. She suffered a lumbar compression fracture related to an accident. A magnetic resonance imaging (MRI) scan completed of her lumbar spine showed compression deformities of her lumbar vertebra (L [lumbar]1, L2), multilevel degenerative disc disease, and facet arthropathy contributing to bilateral foraminal stenosis. The patient completed weeks of conservative treatments within a few months without relief of her pain. A right lumbar medial branch block (LMBB) was recommended for all 4 joints from lumbar vertebra 2 (L2) to sacral vertebra 1 (S1).

This patient has multiple pain generators, and the standard of care is to treat the other pain generators first. According to Centers for Medicare & Medicaid Services [CMS] published guidelines regarding the performance of facet blocks, they can be performed only when: "Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst). There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity." (1)

Manchikanti et al noted "Accurate selection of patients for diagnostic and therapeutic modalities with facet joint pain, meeting appropriate medical necessity and indications, is crucial. Recent evaluation of utilization of interventional techniques and facet joint interventions in particular have shown significant changes in utilization patterns." (2)

Cohen et al found that physical exam findings were not very specific and diagnostic blocks were the only way to make the diagnosis. Even then there is a high false positive rate. (3) This supports the CMS guideline. 

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

The insurer's denial of coverage for pain management is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Liver Biopsy
The insurer denied a liver biopsy. The health plan's determination is upheld. 

The patient is a woman who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy). The records support that she had a body mass index (BMI) of 39. The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of marked steatosis.
The provider submitted current procedural terminology (CPT) code 47379 (liver biopsy, wedge). This is under review.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy.
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
In this case, the patient is morbidly obese with a body mass index of 39. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

Per clinical documentation, the patient presented to the emergency department with a one-day history of abdominal pain. The patient was status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, and open ventral hernia repair. There was no nausea or vomiting. Vital signs were within normal limits. The patient had a computed tomography (CT) scan that indicated "appendix is suspicious." The patient was also noted to have an engorged bladder. White blood cell count was 9.90. There were no wound complications noted from the previous surgery. The patient underwent an uneventful laparoscopic appendectomy. 

Admission may be necessary for patients with severe systemic illness, poorly controlled comorbidities, or complications from the procedure that require more than 24 hours of postoperative care [1-3]. There were no immediate complications documented after the surgery. The patient's diet was advanced as tolerated. The patient was ambulating appropriately. Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis [1-3]. Therefore, the requested inpatient admission was not medically necessary. 

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 hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Stroke.
Treatment: Admission to Skilled Nursing Facility.

The insurer denied the admission to Skilled Nursing Facility.  The denial is upheld.

The patient is a female who suffered a massive subarachnoid and intraventricular hemorrhage secondary to a middle cerebral artery aneurysm. She initially did not progress with rehab and was discharged home. Since that time, she has made neurologic recovery with therapy provided and is more cognitively capable of participating in therapy.

Admission to the SNF (skilled nursing facility) was requested. It was initially denied as not medically necessary. This is the subject of the appeal.

No, the requested admission to skilled nursing facility is not medically necessary.
The patient suffered a hemorrhagic stroke and has continued neurologic deficits and functional impairments. She is receiving therapy in the home. She continues to require maximal assistance with bed mobility and total assistance with transfers. Standard of care for admission to SNF (skilled nursing facility) is the need for daily skilled rehabilitation or skilled nursing services. At this point in her recovery, her care would be considered custodial. Further significant improvement in a reasonable and predictable period of time is not expected. Admission to the SNF (skilled nursing facility) for rehabilitation is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The admission to the skilled nursing facility would not be considered reasonable and necessary due to the patient's ongoing deficits and lack of improvement with prior therapy. The denial was reasonable.
Appeal type: Medical necessity
Decision: Upheld

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


The patient presented with 1 day of abdominal pain. She was seen at an outside facility and told to go to the emergency department (ED). In the ED she had an ultrasound (US) which showed some free fluid but could not visualize the appendix. She was two weeks post menstrual cycle. She was also sexually active. She underwent an abdominal computed tomography (CT) scan which was consistent with acute appendicitis. There was no fluid on the CT scan. Her white blood cell count (WBC) was elevated at 16.9. She had an uneventful laparoscopic appendectomy at which time they did not find any abscess or perforation. The pathology report confirms this. Her diagnosis is acute uncomplicated appendicitis. At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary. In uncomplicated simple appendicitis, a lower level of care is appropriate.
A study by Kansas City (reference 5) showed in a retrospective analysis: After laparoscopic appendectomy in children with nonperforated appendicitis, same day discharge not only reduces postoperative length of stay but also is not associated with higher hospital readmission rates.
A lower level of care is reasonable and effective. The first reference confirms that the care delivered to this patient was within the standard of practice. This patient required pain medication postoperatively and had some drops in heart rate, which can occur after surgery. No treatment was provided for the bradycardia The third reference indicates implementation of an ERAS protocol significantly decreases length is stay
Reference 4 concludes: This study suggests that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients.
This patient had simple appendicitis, as evidenced by the operative report and the pathology report. Implementing an enhanced recovery after surgery (ERAS) protocol can be helpful in standardizing care and facilitating discharge. An inpatient stay was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Female Infertility (n97.8).
Treatment: Embryo Biopsy (BX OOCYTE MICROTQ and BX OOCYTE MICROTQ >5 EMBRY) (89290 & 89291).

The insurer denied the Embryo Biopsy (BX OOCYTE MICROTQ and BX OOCYTE MICROTQ >5 EMBRY) (89290 & 89291).  The denial is overturned.

The patient is a female with hypothyroidism and infertility.  She is a carrier of Cohen syndrome, combined SAP (saposin) deficiency, and nemaline myopathy.  She has undergone assisted reproduction with IVF (in vitro fertilization).  Due to her age and genetic carrier status, she underwent preimplantation genetic testing of the 9 embryos developed in the process.  6 were abnormal.

The PGT (Preimplantation Genetic Testing) was denied as experimental/investigational.  She is appealing this determination.

Yes, the health plan should cover the requested health service.

According to Schattmann, there are different types of preimplantation genetic testing:

There are three types of preimplantation genetic testing (PGT, formerly known as PGD or preimplantation genetic diagnosis). All require in vitro fertilization (IVF); biopsy of an embryo, or less commonly polar body/bodies (I and II), for genetic testing; and then transfer of selected fresh or frozen-thawed embryos into the uterus based on the results of genetic testing.

Preimplantation genetic testing for aneuploidy (PGT-A) was formerly called preimplantation genetic screening. The goal of PGT-A (preimplantation genetic testing for aneuploidies) is to identify embryos with de novo aneuploidy, including subchromosomal deletions and additions (duplications), in embryo(s) of parents presumed to be chromosomally normal. Theoretically, avoiding transfer of these embryos will reduce the risk of miscarriage and complications related to pregnancy failure and improve the probability of conceiving a viable pregnancy.

Indications for PGT-A (preimplantation genetic testing for aneuploidies) is advanced maternal age as well as known carrier status of specific disease processes.

In review of the medical record the patient is over the age of 40 with infertility.  She is also a carrier of Cohen syndrome, combined SAP deficiency, and nemaline myopathy 2.  The literature supports that PGT-A (preimplantation genetic testing for aneuploidies) is medically appropriate for this clinical scenario.  This follows the accepted standard of medical practice, not for convenience, and not more intensive than alternative options for aneuploidy detection.

Yes, the requested service is more beneficial.

PGT-A (preimplantation genetic testing for aneuploidies) is performed prior to implantation or transfer of the embryo.  Therefore providing the earliest data in order to prevent chromosomal abnormalities.  The other aneuploidy screenings can only be performed after pregnancy has been achieved.  Given this patient's age and history as a carrier of several genetic diseases, this test is appropriate and more beneficial to ensure a healthy viable pregnancy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematoma and Cellulitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

About two and a half weeks after sustaining leg trauma from being struck by a car while riding his scooter (no fracture), the patient was diagnosed with a hematoma and cellulitis by an Orthopedic Surgeon, who prescribed Keflex. The patient returned to the ED (emergency department) for increased redness and swelling to the left leg. The ED provider's note documents that redness had increased, and swelling had not improved. The area of suspected cellulitis was 7x8 cm (centimeters), with no fluctuance and the absence of an abscess was confirmed by sonogram done in the ED.

The vital signs were stable throughout the ED stay and there were no clinical or laboratory signs of sepsis, and no concern of sepsis in the ED or the pediatric admission notes.  The medical decision statement stated he was well appearing, and the note does not present any justification for inpatient care. He was able to bear weight and had no constitutional symptoms.  

The CRP [C-reactive protein] and ESR [erythrocyte sedimentation rate] were elevated, consistent with an inflammatory process or infection.

The admission was not medically necessary. There was no evidence of deep soft tissue, fascial or muscle involvement or of deep vein thrombosis, and he was not immunocompromised. The patient most likely had a staphylococcal infection of his hematoma. He did not respond to cephalexin most likely because it was a methicillin resistant strain (MRSA), and clindamycin is the appropriate choice for suspected MRSA, but because clindamycin is orally bioavailable it did not need to be admitted intravenously.  Monitoring for any progressions or improvement could be accomplished with follow-up in the outpatient setting. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. A small area of cellulitis can be treated as an outpatient (Lawrence, 2012) because it does not pose a danger of spreading to any vital structure or organ. IV (intravenous) antibiotics are usually unnecessary (Kaplan, UpToDate, Raff, 2016 and Stevens, 2014).

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decompensated Congestive Heart Failure

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

The patient is a gentleman that presented to the hospital complaining of dyspnea.  Past medical history was significant for heart failure with reduced ejection fraction (LVEF [left ventricular ejection fraction] 10% (percent)), atrial fibrillation, and left ventricular apical thrombus and polysubstance abuse. Upon arrival to the hospital, vital signs were stable (pulse 100, blood pressure (BP) 108/76).  Physical examination was significant for a distended abdomen with ascites. Twelve-lead electrocardiogram (ECG) revealed sinus tachycardia at 110. Serum blood testing revealed elevated high sensitivity troponin (111) and Brain type natriuretic peptide (4699). Echocardiogram was significant for severe biventricular failure, moderate mitral regurgitation (MR) and moderate tricuspid regurgitation (TR). The patient was admitted to telemetry for monitoring and treatment. He was treated with intravenous diuretic agents and ultimately signed out against medical advice. 

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with shortness of breath and acute on chronic congestive heart failure.  On physical examination, he was tachypneic with abdominal distension and ascites.  Laboratory testing revealed an elevated brain natriuretic peptide (BNP) level and a severely depressed left ventricular ejection fraction (10%) with moderate MR was noted. The patient responded was treated with diuretics and ultimately signed out against medical advice.  Failure to admit and treat this patient would have resulted in excess morbidity or even mortality.  Patients with chronic congestive heart failure and renal insufficiency have a high risk of adverse outcomes warranting a higher level of care (Reference 1). In one study, patients presenting with congestive heart failure and an elevated BNP level (greater than 200) were found to have an increased morbidity and mortality in the subsequent 90 days (Reference 2). In conclusion, this patient had decompensated congestive heart failure and required intravenous diuretic therapy. (Reference 3) Inpatient hospital admission was medically necessary in this case.

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

Diagnosis: Age-related decrease in ovarian reserve

Treatment the requested IVF (in vitro fertilization) services using donor eggs

The insurer denied coverage for the requested IVF services using donor eggs

The denial is upheld

The patient is a female interested in conceiving. She has a diagnosis of age-related decrease in ovarian reserve. The request is for an and IVF cycle frozen embryo transfer with donor eggs.

It is important to understand that fertility declines as a woman age due to the normal age-related decrease in the number of eggs that remain in her ovaries. This decline may take place much sooner than most women expect. Fertility gradually declines as a woman age. Each month that she tries, a healthy, fertile woman has a 20% (percent) chance of getting pregnant. That means that for every 100 fertile women trying to get pregnant in 1 cycle, 20 will be successful and the other 80 will have to try again. At an advance maternal age, a woman's chance is less than 5% per cycle, so fewer than 5 out of every 100 women are expected to be successful each month. These percentages are true for natural conception as well as conception using fertility treatment, including IVF. The age-related loss of female fertility happens because both the quality and the quantity of eggs gradually decline.

According to published SART (society for assisted reproductive technology) data, the national success rate (live birth per IVF cycle) in of advance maternal age is 4.5%. This is not much different from a woman trying to conceive through intercourse unless she has blocked tubes or a severe male factor.

IVF cycle frozen embryo transfer with donor eggs is not medically necessary for this patient for the following reason: This patient has an age-related decrease in ovarian reserve. It has become clear that the decline in fertility with increasing female age is largely due to a rapid decrease in oocyte (egg) quantity and quality, with a higher proportion of oocytes displaying genetic abnormalities. In other words, this patient does not have a disease condition, she has a normal age-related decrease in her ovarian reserve and therefore since she has no disease condition, treatment is not medically necessary. IVF cycle frozen embryo transfer with donor eggs for this patient is not medically necessary.

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

The insurer's denial of coverage for IVF cycle frozen embryo transfer with donor eggs is upheld. Medical necessity is not substantiated.