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

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

The patient is a female with a significant medical history of cerebral cavernous hemangioma and lumbar laminectomy/diskectomy. She has worsening back and leg pain. Her pain is worse with prolonged sitting, sit-to-stand transitions and lumbar extension. She previously underwent lumbar radiofrequency ablation with excellent pain relief. Physical exam was unremarkable. Lumbar spine magnetic resonance imaging (MRI) showed a moderate left paracentral/subarticular protrusion causing moderate left sub articular and neural foraminal stenosis at L (lumbar) 3-4, small disc bulges at L4-5 and L5-S (sacral)1, and Modic type 1 changes at L3-4. 

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.
The Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has back pain and leg pain. She responded well to the prior radiofrequency ablation for facet joint pain. MRI revealed a significant disc protrusion at L3-4 level. Truumees's study supported the efficacy of Intracept procedure vertebrogenic back pain. However, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. Given this patient's medical history, MRI reading, and the current clinical evidence, the proposed procedure is not likely to be more beneficial than any standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Calcification of the left anterior descending artery
Treatment: CPT code 78431
The insurer denied coverage for: CPT code 78431
The denial is: Upheld
This is the case of an adult patient who was asymptomatic with a history of hyperlipidemia who underwent screening computed tomography (CT) angiography. The patient was noted to have a calcium score of 1419 units with calcification of the left anterior descending artery noted. The patient reported brisk exercise 2 days per week and had no symptoms of dyspnea or chest discomfort. Physical exam revealed no abnormality (body mass index [BMI] 27, Blood Pressure 120/81 millimeters of mercury [mmHg]). 12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with poor R wave progression. The patient was referred for functional testing utilizing positron emission tomography/computed tomography (PET/CT) imaging.

The Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial randomized more than 10,000 patients suspected of having coronary artery disease (CAD) to imaging with computed tomography (CT) angiography or functional testing such as stress testing. Results demonstrated no significant difference in the primary outcome of all-cause mortality, myocardial infarction hospitalization for unstable angina, or major complications of cardiovascular procedures. Reference (1). 

The Scottish Computed Tomography (SCOT) Heart trial supported the use of adjunctive exercise ECG testing following CT angiography. (Reference 2). 

Current European Society of Cardiology (ESC) guidelines provide a IIb indication for performing CT calcium score for risk assessment in asymptomatic individuals. The same guidelines do not recommend functional imaging in nondiabetic, asymptomatic patients (class III indication harm). (Reference 3) The American College of Cardiology (ACC)/American Heart Association (AHA) appropriate use criteria for detection of and risk assessment of stable ischemic heart disease classify both CT angiography and functional perfusion testing as rarely appropriate. (Reference 4) In conclusion, stress testing with imaging (PET/CT) imaging CPT code 78431 is not medically necessary for this patient. 

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 CPT code 78431 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: substance abuse
Treatment: Substance abuse inpatient
The insurer denied Inpatient Substance Abuse Admission 
The health plan's determination is overturned. 

The patient is an adult female who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol and stimulant (crack cocaine) use disorders. The patient was using up to one gallon of liquor daily together with daily use of $ (dollar) 40 worth of crack cocaine.
The patient presented with alcohol withdrawal symptoms at the time of admission. Withdrawal symptoms included tremor, sweats, nausea and abdominal pain, insomnia, and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 10. The patient has a history of psychiatric disorder best characterized as unspecified anxiety and depressive disorders, as well as history of childhood emotional and physical abuse. 

Inpatient Substance Abuse Admission was medically necessary for this patient.
The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol and cocaine use disorder, and other services noted in the clinical summary, could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with a lack of insight, high risk for relapse and lack of a reasonable recovery environment, and comorbid psychiatric disorders including trauma history.
Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin and nicotine replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Sebopsoriasis
Treatment: Clobetasol Shampoo
The insurer dened Clobetasol Shampoo.
The determination is upheld.

The patient is a female with sebopsoriasis. She has previously been prescribed Clobetasol lotion, Clobetasol scalp solution, betamethasone lotion, fluocinolone solution, and fluocinolone shampoo. The prescriber is a dermatologist. The medication under review is Clobetasol shampoo. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
The formulary drug would not be ineffective, and would be as effective as the non-formulary drug. The formulary drug would not have adverse effects. Clinical guidelines for the management of seborrheic dermatitis recommend the use of Clobetasol foam for seborrheic dermatitis. According to the current evidence-based dermatology literature, the preferred medicines such as clobetasol foam are effective treatments for the management of seborrheic dermatitis (1-3). The preferred agents are appropriate agents for the treatment of the patient's seborrheic dermatitis. There are no comparative, controlled studies showing that clobetasol shampoo has a superior efficacy or safety profile to all of the formulary alternatives. The formulary medications should be tried and failed prior to initiating clobetasol shampoo. After review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Clobetasol shampoo prior to the formulary alternatives such as Clobetasol foam.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The patient is an adult with past medical history significant for rheumatic fever who presented to the emergency room (ER) with complaints of cough, congestion, and flu-like symptoms. 

Vital signs on presentation included: Temperature - 98.9 Fahrenheit, Blood Pressure - 141/63, Pulse - 104, Respiratory Rate - 20, oxygen (O2) saturation - 99% (percent) on room air. Laboratory values were notable for the following: White blood cell count (WBC) - 15.8k, hemoglobin (Hgb) - 12.3, hematocrit (Hct) -36, creatinine - 0.66, glucose - 88.

The patient was empirically started on antibiotics (Doxycycline and Ceftriaxone) and intravenous (IV) fluids. Chest radiographic image (CXR) showed hazy airspace opacities in the right lung base medially. The patient improved clinically, remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management. 
     
According to medical records, the patient presented with tachycardia (heart rate-104), hypertension, and laboratory abnormalities including elevated WBC (15.7k). CXR was suggestive of pneumonia. Based on the above findings in a patient with history of rheumatic fever, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation.

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 inpatient is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is the case of a patient who presented to the hospital with suicidal ideations.  While in the psychiatry ward, the patient reported chest pain. The patient had a history of multiple admissions for chest pain. The patient described stabbing left sided chest pain for 3 weeks, radiating to the right side of the chest.  The patient's past medical history was significant for ventricular tachycardia and systolic congestive heart failure due to left ventricular non compaction.  An implantable cardiac defibrillator was in situ.  It had not fired. On evaluation, vital signs were stable and physical examination revealed no abnormality. A 12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities. Serum blood testing revealed normal troponin levels (5). The patient was transferred to the telemetry ward for further work up.  An echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40% with severe right ventricular dilatation. A computed tomography (CT) of the chest revealed no evidence of pulmonary embolism or aortic dissection. Ultimately, following treatment with guideline directed medical therapy the patient was transferred back to the psychiatry ward.

The health plan did not act reasonably, with sound medical judgment and in the best  interest of the patient.  This patient presented with suicidal ideations and chest pain.  The patient had prior admissions for chest pain. On this admission the symptoms were highly atypical. There were no findings of acute congestive heart failure (CHF),  the troponin levels were normal and the ECG showed no acute changes. In conclusion, admission to the hospital was not medically necessary.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a female admitted for diagnosis of community acquired pneumonia (CAP). The patient presented with a chief complaint of chest pain for three days prior to admission. She had no fever or cough. Vital signs demonstrated blood pressure 98/58, pulse 95, temperature 36.9C, respiratory rate 17 and oxygen saturation 100%. Physical exam showed no acute distress or altered mental status. White blood cell count was 15.4 with potassium 3.1 and creatinine 0.7. Chest x-ray showed pneumonia in the middle right lower lung zone. 

The inpatient hospital admission was not medically necessary. The patient in this case was admitted and treated for community acquired pneumonia but could have been managed at a lower level of care. She did not have alcoholism, or immunosuppression. She did not have hypoxia, hemodynamic instability, sepsis or fever. She did not have altered mental status. She had a pneumonia risk class score of II with a 0.6 to 0.9% mortality which is considered reasonable for outpatient treatment. She was treated with standard measures including doxycycline and ceftriaxone with improvement of symptoms and white blood cell count.
Although the patient required services in the hospital setting the monitoring, the diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care. Therefore, the inpatient admission was not indicated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a medical history of chronic obstructive pulmonary disease (COPD), alcohol use, polysubstance abuse, and liver cirrhosis, who presented with right lower extremity pain and shortness of breath. The patient is a daily smoker.
The review of systems was negative for additional complaints. The physical examination was remarkable for bilateral expiratory wheezes.
The patient was admitted for suspected cellulitis and COPD exacerbation. The patient was treated with duonebs and intravenous (IV) SoluMedrol. A chest x-ray and computed tomography (CT) angiogram were negative for remarkable acute changes. The patient left against medical advice. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital admission was not medically necessary. The patient did not meet criteria for inpatient level of care. COPD exacerbation was mild and responded to steroids and nebulizers. The patient did not have hemodynamic instability, or evidence of hypoxia or respiratory failure.
In general, more than 80 percent of exacerbations of chronic obstructive pulmonary disease (COPD) can be managed on an outpatient basis. There are certain criteria that might lead to a decision to hospitalize the patient have been proposed in the The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and include:
.	Inadequate response to outpatient or emergency department management
.	Onset of new signs (eg, cyanosis, altered mental status, peripheral edema)
.	Marked increase in the intensity of symptoms over baseline (eg, new onset resting dyspnea) accompanied by increased oxygen requirement or signs of respiratory distress
.	Severe underlying COPD (eg, forced expiratory volume in one second [FEV1] less than or equal to [<=]50 percent of predicted)
.	History of frequent exacerbations or prior hospitalization for exacerbations
.	Serious comorbidities including pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, or liver failure
.	Frailty
.	Insufficient home support
In this particular case, the patient did not have documentation to support any of the above, therefore, the inpatient level of care was not justified based on the GOLD criteria. A lower level of care for nebulizer and steroids followed by transition to outpatient care would have been most appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right arm laceration and left-hand laceration status post assault
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This patient presented to the emergency department via ambulance with complaints of a right arm laceration and left-hand laceration status post assault. He was transferred from an outside facility for vascularization of the digits after an assault with a knife. He stated that he had numbness and weakness in the left hand. He had stab wounds to the left and right arms, a partial amputation to the left digit, and laceration to right forearm. He was subsequently admitted for a laceration without a foreign body of the left forearm. He underwent a repair of the right forearm laceration, left palmar laceration exploration, repair of the flexor digitorum profundus (FDP) tendons to the index, middle ring and small fingers left, repair flexor pollicis longus (FPL) tendon left, repair common digital nerves to second, third, and fourth web space left, repair of ulnar and radial digital nerves to thumb left, repair of common digital arteries to third and fourth web space left, repair of dorsal vein of left small finger, repair of extensor digitorum communis (EDC) to the left small and ring fingers, left carpal tunnel release, open reduction percutaneous pinning of left small finger proximal phalanx fracture, and open reduction percutaneous pinning of left ring finger metacarpal head fracture. He had an uneventful postoperative course and was discharged.
An inpatient admission was not medically necessary. This patient required repair of multiple bilateral hand injuries including revascularization. Although the procedure was protracted, most hand surgery can be done at an outpatient level of care. In this case, because the patient required revascularization, overnight observation was indicated. Admission, however, was not required. According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable and needed only additional analgesic medication. He could have been safely managed at a lower level of care. The patient was medically stable other than his hand injuries, and most hand surgery can be performed at an ambulatory level of care. In this case, observation was appropriate for monitoring of circulation and for pain management. He was safely sent home the following day after surgery. He did not have any other pressing medical issues.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ventricular tachycardia
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 (ED) after an episode of palpitations and a heart rate in the 160s. His medical history was remarkable for arrhythmogenic right ventricular cardiomyopathy, cardiac arrest and implantation of a subcutaneous implantable cardioverter defibrillator (S-ICD). He was being treated with metoprolol and flecainide. At the time of presentation, an electrocardiogram showed a wide complex tachycardia at 160 beats/minute. The patient was treated with intravenous procainamide. An electrocardiogram showed sinus rhythm with frequent premature ventricular complexes and ventricular couplets. Interrogation of his S-ICD showed that the patient's presenting arrhythmia had been sustained ventricular tachycardia.

The inpatient hospital admission was medically necessary for this patient.
This man, with a history of arrhythmogenic right ventricular cardiomyopathy (ARVC) and cardiac arrest, presented after an episode of sustained ventricular tachycardia (VT) that was below the ventricular tachycardia rate cutoff of his subcutaneous implantable cardioverter defibrillator (S-ICD). Upon presentation, he had frequent ventricular ectopy and ventricular couplets. Quinidine was prescribed and the dose was titrated based on the frequency of his ectopy and his QT interval. While the patient's antiarrhythmic drugs were adjusted he was at risk for recurrent sustained VT, a life-threatening arrhythmia, due to his ARVC. He was also at risk for torsades de-pointes, a potentially lethal arrhythmia that can result from a proarrhythmic effect of antiarrhythmic drugs such as quinidine. He required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Deep bite.
Treatment:  Braces.
The insurer denied Braces.  The denial is overturned.

The patient is a teenage male requesting orthodontic treatment. He has a Class II malocclusion with a deep bite. Also, he has moderate upper and lower jaw crowding. The prior denial was due to there being "no need to fix a serious head or facial medical problem".

The requested health service is medically necessary.

The patient has a deep, impinging overbite with soft tissue damage to his palatal gum tissues. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient has a history of recurrent vasovagal syncope and recurrent uncomplicated sigmoid diverticulitis. The patient was recently hospitalized for diverticulitis and given antibiotics. An extensive workup for the syncope was negative. A colonoscopy showed diverticulosis but no signs of acute diverticulitis or malignancy. The patient was afebrile and the vital signs were stable. Mild left lower quadrant LLQ) tenderness was present without rebound or guarding. There was no leukocytosis. A computed tomography (CT) scan done a few days earlier had shown acute diverticulitis without an abscess or perforation. Antibiotics were again given. The patient was advised to see a surgeon as an outpatient to discuss a surgical resection in view of their recurring attacks of diverticulitis. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality on imaging studies. This abnormality can be a fistula, obstruction, or free perforation. The patient did not have these conditions. The patient also did not need a drainage procedure, have bacteremia, severe vomiting, or an inability to maintain oral hydration after observation care. 

This patient had recurrent episodes of diverticulitis. The patient could have been started on intravenous (IV) antibiotics with observation care and then discharged on oral antibiotics. The patient was advised to have an elective surgical resection but did not need any acute interventions at this time. The patient did not meet MCG criteria for admission for Acute Diverticulitis. 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.