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

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented with right lower quadrant (RLQ) abdominal pain. The patient had a low-grade fever but was hemodynamically stable. There were no peritoneal signs. The white blood cell (WBC) count was 14.3. A computed tomography (CT) scan was read as acute uncomplicated appendicitis. Intravenous (IV) antibiotics were started and the patient rapidly improved. The patient was discharged on oral antibiotics the next day with a plan to follow up in the surgery clinic. 

Clinical indications for admission for Milliman Care Guidelines (MCG) guideline for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bowel perforation or obstruction, bacteremia, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

MCG guideline for Gastroenterology (MG-GAS) lists nonoperative management of acute appendicitis as indicated by having a hemoperitoneum. The patient did not have a hemoperitoneum. The patient also did not have hemodynamic instability, peritoneal signs, mesenteric ischemia, or free air. 

This patient had abdominal pain and CT scan evidence of appendicitis. Due to the patient's rapid improvement, they did not have surgery at this time. If a laparoscopic appendectomy were done, it could have been performed as ambulatory surgery. The patient could have been treated with observation care and then discharged on oral antibiotics. The patient did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Gastroenterology. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

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 Inpatient Admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease, osteoarthritis, legal blindness in right eye, low vision in left eye, and polycythemia vera
Treatment: Increase Home/Personal Care HHC (Home Health Care) Level 2 Per 15 minutes Increase to 49 Hours per Week
The insurer denied: Increase Home/Personal Care HHC (Home Health Care) Level 2 Per 15 minutes Increase to 49 Hours per Week
The denial is upheld.

The patient is an elderly female. Her medical conditions that include Alzheimer's disease, osteoarthritis, legal blindness in right eye, low vision in left eye, and polycythemia vera. Denial 
of increase home/personal care to 49 hours per week is being appealed. The health plan approved 35 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows minimally impaired cognition and functional status requires assistance with all activities of daily living (ADLs), except walking, locomotion, toileting, bed mobility, and eating. She has frequent bladder incontinence. She was hospitalized 4 months ago after a fall resulting in a back fracture. She did not require surgery. She lives with her son and daughter-in-law since hospitalization. Compared to Uniform Assessment System evaluation completed 5 months ago, she had a change from independent walking and locomotion from independent to supervision. 

The Increase Home/Personal Care HHC Level 2 Per 15 minutes Increase to 49 Hours per Week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase home/personal care to 49 hours per week is being appealed. The health plan approved 35 hours per week. This patient has multiple medical conditions, including recent hospitalization after back fracture. She lives with her son and daughter-in-law since hospitalization. Uniform Assessment System (UAS) evaluation completed 3 months ago shows she requires assistance with all activities of daily living (ADLs), except walking, locomotion, toileting, bed mobility, and eating. Compared to Uniform Assessment System evaluation completed 5 months ago, she had a change from independent walking and locomotion from independent to supervision. She has bladder incontinence. The information provided does not support significant decline in the patient's functioning between Uniform Assessment System evaluations. Home/personal care is not indicated for safety supervision. The requested increase in home/personal care services from 35 to 49 hours per week is not medically indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibroid uterus
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who underwent a robotic assisted total laparoscopic hysterectomy with bilateral salpingectomy, uterosacral vault suspension, and cystoscopy for a fibroid uterus. She was admitted post operatively for pain management. She was having nine out of ten pain post operatively. The patient's pain improved overnight. Her vitals were stable. Her post-operative blood levels were normal. By the next day, the patient was voiding, ambulating, tolerating diet, and pain was controlled. She was discharged home. The inpatient stay has been denied as not medically necessary. This is being appealed.

The requested health service was not medically necessary.

According to the American College of Obstetricians and Gynecologists (ACOG), "The ERAS (enhanced recovery after surgery) principles represent an evidence-based approach to surgical management that challenges traditional surgical management paradigms. The use of ERAS pathways has resulted in more rapid surgical recovery, shorter length of stay, and greater patient satisfaction when compared with traditional approaches. These benefits have been replicated across the spectrum of gynecologic surgeries, including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the ERAS program requires collaboration from all members of the surgical team. Successful ERAS pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems, and the use of ERAS pathways should be strongly encouraged within institutions."
This patient in question was taken to the operating room and underwent an uncomplicated procedure for a fibroid uterus. After surgery, the patient was not ready for discharge same day due to her severe pain of nine out of ten. She required observation and nursing care to assist with her ambulation and medical management of her pain. However, this could have been done at a lower level of care. By post-operative day #1, the patient was ready for discharge requiring less than a 24 hour stay. Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive emergency

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.
 

Asked to review the case of an adult gentleman that presented to the hospital with complaints of lightheadedness, diaphoresis, palpitations, chest pain and diarrhea.  Past medical history was significant for substance abuse disorder, hypertension, gastroesophageal reflux disease, and bipolar depression. The patient admitted to sniffing heroin prior to admission.  On arrival to the hospital the patient was hypertensive and tachycardic: Blood Pressure (BP) 191/126, Pulse 125.  Physical exam was significant for rhinorrhea.  12 lead electrocardiogram demonstrated sinus rhythm with non-specific ST/T wave abnormalities.  Serum blood testing was significant for elevated potassium (5.1), creatinine (1.6)(Cr), and high sensitivity troponin (25). Urine toxicology was positive for cocaine.  The patient was admitted to the hospital for treatment of hypertensive emergency and drug withdrawal. Echocardiogram demonstrated normal wall motion and ejection fraction. The patient was treated with nitroglycerin and labetalol therapy and ultimately discharged once BP was controlled.  

Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1)  This patient presented with a systolic BP of 191. His Troponin and Cr levels were elevated consistent with left ventricular and renal target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Admission to the hospital for aggressive blood pressure management was necessary in this case. In fact, American Heart Association guidelines recommend admission to the intensive care unit  (ICU) for management of hypertensive emergencies (Reference 1).  Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine abuse, found that patients over age 50 had an elevated risk of major adverse cardiac events and mortality. They concluded that such patients required hospital admission. (3). In conclusion inpatient admission was medically necessary.

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins.
Treatment: Radiofrequency Ablation (36475 x 1).
The insurer denied: Radiofrequency Ablation (36475 x 1).
The denial is overturned.

This patient is an adult male who presents with bilateral leg pain, the left worse than the right. He has noticed progressive varicose veins and some swelling. He has used compression stockings for two years without relief. The symptoms cause a moderate effect on activities of daily living. Duplex testing shows left great saphenous vein (GSV) enlargement (7.6 millimeters) and severe reflux (500-2000 milliseconds). Ankle Brachial Index (ABI) is 1.0 bilaterally. The provider has recommended left great saphenous vein ablation. Coverage has been denied on the basis that the 
records do not show adequate arterial perfusion to the legs.

The requested health service is medically necessary.

Under widely accepted criteria (1-4), endovenous ablation of an axial saphenous vein is medically necessary when: 
1) The patient has venous insufficiency symptoms severe enough to affect normal function. 
2) The patient has failed a trial of prescription compression stockings. 
3) The patient has duplex-proven reflux affecting the vein in question and the reflux can be reasonably construed as a cause of the patient's symptoms.
Requirement 1 has been met. The office notes and a vein questionnaire describes symptoms that adversely affect the patient's daily activities to a moderate degree. 
Requirement 2 has been met. 
According to the office notes and the vein questionnaire, the patient had incomplete relief of symptoms after a two-year trial of compression stockings. 
Requirement 3 has been met. 
The target vein (left great saphenous vein) is enlarged at 7.6 millimeters and exhibits severe reflux, duration ranging from 500-2000 milliseconds.
Therefore, the patient meets published, well-accepted criteria for ablation of the left great saphenous vein. The requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay.
The health plan's determination is overturned.

This is a male patient with a history of seizures, atrial fibrillation, status post cardioversion, cardiomyopathy (ejection fraction (EF) 30 percent (%)  and alcohol abuse (1 pint of alcohol (ETOH) 3-4 times per week) who presented to the emergency room with dyspnea and weakness. He was noted to have rapidly conducted atrial fibrillation. He was transferred and admitted to inpatient telemetry. His heart rate was 135 beats per minute (bpm) in atrial fibrillation. He was treated with intravenous digoxin and intravenous heparin. Electrophysiology was consulted for possible cardioversion. An echocardiogram (ECHO) was performed showing severe global left ventricular hypokinesis. Coreg was restarted for rate control and cardiomyopathy. He was started on Entresto, spironolactone and a sodium glucose co-transporter 2 (SGLT2) inhibitor. There was a plan for a transesophageal ECHO and electrical cardioversion. However, the patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay.

The requested service of inpatient admission is medically necessary for this patient.
The patient meets criteria for inpatient admission. He does have cardiomyopathy, possibly ETOH-induced, and presented (was transferred) with atrial fibrillation with rapid ventricular rates. After 24 hours, he remained with uncontrolled ventricular rates in atrial fibrillation (AF) (120s-140s on telemetry, per progress notes). Per Milliman guidelines, inpatient admission is indicated for patients with atrial fibrillation who have hemodynamic instability, with one indication being persistent uncontrolled ventricular rates in atrial fibrillation. That is the situation for this patient. He required additional hospitalization for ventricular rate control and there was plan for this with transesophageal echocardiogram (TEE) and cardioversion. Other indications for continued hospitalization included severe hypomagnesemia, less than (<) 1. He left against medical advice prior to completion of treatment.
Inpatient admission is indicated, per standard guidelines, including American College of Cardiology (ACC)/American Heart Association (AHA) (reference provided with initial review).  The guidelines indicate that cardioversion may be urgently needed for patients with new onset AF and conditions including intractable ischemia, hemodynamic instability, or inadequate rate control.  That is the situation for this patient, with inadequate rate control and congestive heart failure (CHF) in the setting of AF.
Appeal type: Experimental/Investigational
Decision: Upheld

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

The patient is a female with a history of chronic low back pain. She is seen by Neurosurgery for worsening of her low back pain over the last 6-8 months. She had no radicular pain. Her pain was worse with positioning and was unable to rise from a bending position due to stiffness and pain in the low back. Her pain was rated 5/10. Medication alleviated her pain temporarily. She had physical therapy in the last year without success and Norco and medical marijuana with little success. Her magnetic resonance imaging (MRI) noted Modic changes at L (lumbar)4-5 and S (sacral) 2 Tarlov cyst. Her intake form noted medications of Norco, gabapentin and ibuprofen. She had chiropractic care, physical therapy and home exercise program. 

The intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment for her condition. The patient has multiple pathologies that could be causing her symptoms that include severe facet arthropathy at L5-S1 and a large Tarlov cyst at S2. These pain generators have not been ruled out. Furthermore, significant facet arthrosis has been excluded during the Intracept trials which would make the procedure outside of the standard of care at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

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

This is a female with a history of chronic low back pain. She has had physical therapy and medications without relief. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows degeneration and Modic changes at L (lumbar)4-5. The provider has recommended the Intracept procedure (Intraosseous Basivertebral Nerve Ablation).

The Intraosseous Basivertebral Nerve Ablation 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.
While this is a promising technology, the literature describes further research needing to be performed, particularly from non-industry sources. Urits et al cite "CLBP (chronic low back pain) is a difficult yet common diagnosis that affects a significant portion of patients worldwide. In efforts to combat this debilitating disease, researchers have made great progress in understanding the pathophysiology of LBP (low back pain) in addition to unveiling the anatomy of the vertebrae in search of appropriate treatment options. As a result, with the growing evidence supporting the vertebrogenic model that involves the BVN (basivertebral nerve), RF (radiofrequency) ablation of the BVN has emerged as a possible minimally invasive procedure to treat LBP. Several studies have supported the safety, durability, and efficacy of RF ablation of the BVN. There is also convincing evidence that BVN ablation is more beneficial than the current standard of care for the treatment of CLBP. However, reproducible large RCT (randomized control trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

orthopedic
pain management

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

This is a female who has low back pain for 3 years. Her pain is worse over the past 6 to 8 months. She had tried pain medications, chiropractic manipulation and physical therapy (PT), however, none of which provided her without adequate pain relief. Her pain level is 7/10 to 10/10 with a negative impact on her activities of daily living (ADL). Physical exam (PE) was remarkable except limited lumbar spine range of motion (ROM). Magnetic resonance imaging (MRI) revealed Modic changes at L (Lumbar) 4/5 with degenerative disc disease (DDD) and facet arthropathy.

Intraosseous Basivertebral Nerve Ablation Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrated the sustained improvements in pain and function from this intervention for patients with vertebrogenic pain. This patient had failed extensive treatments including Chiropractic manipulation, physical therapy (PT) and pain medications. Her pain is severe with a negative impact on his ADLs. Further interventions are necessary to improve his pain and function. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the intracept procedure is likely to be more beneficial than any standard treatments for the insured's disabling condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations and lightheadedness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult male who presented to the hospital complaining of palpitations and lightheadedness when standing and walking for the past week.  Past medical history was significant for hypertension, diabetes mellitus, atrial flutter and bipolar depression.  Upon arrival, the patient was diaphoretic and tachycardic with a pulse of 120 beats per minute.  Blood pressure was stable at 152/94 mmHg. Physical examination revealed no positive findings other than an irregular rapid pulse.  12 lead electrocardiogram (EKG) revealed atrial flutter with rapid ventricular rate. COVID testing was positive. Serum blood testing revealed hyperglycemia (279 mg/dl), mild elevation in serum troponin (35ng/L), and elevated B type natriuretic peptide (2483). The patient was admitted to the hospital for monitoring and treatment. Heart rate was controlled with beta blocker therapy titration.  The patient signed out against medical advice after two days.

Admission for monitoring and treatment was medically necessary.  Patients presenting with symptomatic atrial flutter and rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital.  American Heart Association/American College of Cardiology Guidelines for the management of patients with atrial fibrillation recommend telemetry monitoring for patients treated with atrial fibrillation requiring treatment with rate control and antiarrhythmic therapies. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation.  In conclusion, inpatient admission was medically necessary in this case.

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 the inpatient admission is substantiated.