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

Diagnosis: Central Nervous System/Neuromuscular Disorder - Chronic migraine.
Treatment: Pain Management. 
The insurer denied Pain management-trigger point injections.
The denial is upheld.

The patient is a female with chronic migraine. She has tried and failed nortriptyline, propranolol, and topiramate for migraine prevention. Her physician intends to initiate Emgality. She was diagnosed with chronic migraine, occipital neuralgia, medication overuse headache, dizziness, and intermittent neck pain. She received occipital nerve blocks and trigger point injections.
At issue is the medical necessity of Pain management-trigger point injections.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Pain management-trigger point injections is not medically necessary for this patient.
The trigger point injections are not medically necessary for this patient. A trigger point is a hyperirritable spot characterized by a palpable nodule in the taut bands of the skeletal muscles fascia. Direct compression or muscle contraction can elicit jump sign, local tenderness, or local twitch. When these are described in the physical examination, treatment with a trigger point injection is medically appropriate. However, the chart note for review does not demonstrate the presence of any trigger points in the physical examination. As such, documentation and support is lacking for a trigger point injection. Furthermore, evidence is lacking to show that trigger points are safe or effective for treatment of headache or chronic migraine as a long-term treatment strategy.
Therefore, the requested health service/treatment of Pain management-trigger point injections is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with medical history of asthma, alcohol abuse, gastric adenocarcinoma, hypogammaglobulinemia on intravenous immunoglobulin, and pancreatitis. He presented to the emergency department with epigastric abdominal pain, nausea, and vomiting. He had consumed 3 liters of vodka on the prior night; he also reported tobacco use. Vital signs were notable for elevated blood pressure of 154/82 and rapid pulse rate of 106/minute. Physical examination was notable for epigastric tenderness. Labs showed hemoglobin of 13.8 and hematocrit of 41.0%, low sodium of 134, elevated alkaline phosphatase of 137 , and elevated direct bilirubin of 0.5. An Ultrasound of the abdomen showed hepatic cirrhosis and steatosis, lack of biliary dilation, normal gallbladder, heterogenous pancreas, and right kidney with parapelvic cyst and partially septated lower pole cyst. Renal ultrasound showed normal-size kidneys, right kidney cysts, partially distended urinary bladder, and bilateral ureteral jets. He was treated with intravenous fluids and morphine. He was placed on a clear liquid diet.

The inpatient hospital admission was not medically necessary. The care provided could have been provided at a lower level of care. In this case, the patient presented with epigastric abdominal pain, nausea, and vomiting. This was consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) or less likely gastroenteritis or pancreatitis. However, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, acute pancreatitis, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction; appropriate therapy was provided with proton pump inhibitor and pain medication. Endoscopy was not deemed necessary. He did not meet criteria for the diagnosis of pancreatitis. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. He did not have documented alcohol withdrawal. All of the measures that were undertaken, such as observation, monitoring, labs, specialist consultations, and proton pump inhibitor therapy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary ciliary dyskinesia (PCD) and rhinosinusitis, and impaired airway clearance. 
Treatment: Airway Clearance Device. 

The insurer denied Durable Medical Equipment- Airway Clearance Device. 
The denial is overturned. 

The patient is a female with complaints of (c/o) primary ciliary dyskinesia (PCD) and rhinosinusitis, and impaired airway clearance. She has been receiving the chest vest, airway clearance device, for some time and has had a positive response. This has prevented pulmonary exacerbations and pneumonia and has shown a positive impact. She has tried manual chest physiotherapy (CPT) but required the airway clearance device for additional airway clearance. 
At issue is the medical necessity of Durable Medical Equipment- Airway Clearance Device. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Durable Medical Equipment-Airway Clearance Device is medically necessary for this patient. 
Positive expiratory pressure (PEP) devices in cystic fibrosis (CF) care have been shown to increase functional residual and total lung capacities and would have similar applicability in PCD patients in accessing the channels of collateral ventilation and mobilizing peripheral mucus. Oscillatory PEP devices cause vibrations of the airway walls, which in CF are used to alter mucus rheology and augment mucociliary clearance, in addition to high-frequency chest wall oscillation (HFCWO), provide oscillatory frequencies similar to normal ciliary beat frequency, which is thought optimal for secretion clearance. High-frequency chest wall compression (HFCWC) assistance devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways. Chest physiotherapy will only help with upper airway clearance. 

HFCWC can lead to changes in volume of 15-57 milliliters (ml) and in flow up to 1.6 liters (L)/second (s), which generates minimal coughing to mobilize secretions. The typical treatment lasts 20-30 minutes and consists of short periods of compression at different frequencies, separated by coughing. Several studies show that HFCWO produced an improvement in several lung function parameters such as higher forced expiratory volume (FEV), lower sputum volume, less days sick, when compared to traditional chest physiotherapy. Hence, the airway clearance device is medically necessary. 

Therefore, the requested health service/treatment of Durable Medical Equipment-Airway Clearance Device is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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


This patient with a history of attention deficit hyperactivity disorder (ADHD), asthma, and vertigo who presented to the emergency department (ED) with a complaint of seizure versus (vs) syncope. The patient was brought to the emergency department (ED) from school by Emergency Medical Services (EMS). A teacher reportedly found the patient unconscious in the school bathroom. The review of symptoms (ROS) was negative for a fever, illness, headache, dizziness, slurred speech, palpitations, shortness of breath, or vision changes. The patient described frequent fainting episodes which had a medical workup by a pediatrician and neurologist and were believed to be attributable to anxiety. Her home medications include Concerta and Seroquel.
The ED vital signs were a temperature (T) 98.4 degrees Fahrenheit (F), heart rate (HR) 113, respiratory rate (RR) 22, blood pressure (BP) 115/65, and oxygen saturation (O2 sat) 100% on room air. A Glasgow Coma Scale (GCS) was 15. She weighed 75 pounds. Orthostatics were normal. The patient was awake and alert on arrival, oriented to person place and time. The physical examination was normal. Blood work including a comprehensive metabolic panel (CMP), creatine kinase (CK), thyroid functions, and troponin were normal. Alkaline phosphatase (Alk phos) was elevated at 240, the white blood cell count (WBC) was 5.5 with normal differential. A urinalysis was normal. Influenza and coronavirus (COVID) testing were negative. The patient was admitted to the hospital for vital sign monitoring, telemetry, and a 24-48 hour electroencephalogram (EEG). The patient was seen in consultation by neurology and cardiology services. A cardiac echocardiogram (ECHO) showed aortic root dilation, consistent with a probable connective tissue disorder. Continuous electroencephalogram (EEG) monitoring was normal. The patient was placed on empiric Keppra medication, a cardiac event monitor, and referred to genetics as an outpatient.
At issue is whether the inpatient hospitalization from was considered medically necessary.

Based on the documentation provided, inpatient stay was not considered medically necessary for this patient. The evaluation and follow-up could have been provided at a lower level of care.
The patient had an unwitnessed brief episode of unconsciousness while at school. Upon arrival to the ED (transported by EMS), she was awake, alert, and oriented. Her vital signs including orthostatics were stable. Laboratory evaluations were normal except for an elevated alk phos. The patient remained stable while on a cardiac monitor in the ED. Further workup and monitoring did not require an inpatient level of care and could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Opzelura 1.5% EX Crea (ruxolitinib).
The insurer denied the Opzelura 1.5% EX Crea (ruxolitinib).
The denial is upheld.

The patient is a female with atopic dermatitis treated with topical steroids and pimecrolimus. The provider is requesting Opzelura cream. The health plan denied the request due to requirement for use of formulary agent Eucrisa.

No, the proposed treatment with Opzelura is not medically necessary.
The health plan requires trial and failure to Eucrisa, which would also be appropriate for this patient. There are no head to head trials of Eucrisa and Opzelura and therefore the medical necessity of Opzelura over Eucrisa cannot be established.

Eucrisa has shown to be effective in mild to moderate atopic dermatitis. In the review by Fahrbach et al, Crisaborole was shown to be superior to vehicle and pimecrolimus and comparable to tacrolimus, 0.1% or 0.03%, with respect to Investigator's Static Global Assessment (ISGA) 0/1 at 2842 days in patients aged two years with mild-to-moderate atopic dermatitis.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Blood Cell Count.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient in this case is a woman with uterine fibroids and anemia.  She was found to have a hemoglobin of 5.9g/dl (grams per deciliter) on outpatient labs and was sent to the ED (emergency department).

The patient's vital signs were notable for tachycardia.  She was not hypotensive.  Hemoglobin in the emergency department was 6.3g/dl (grams per deciliter).  She was admitted to the hospital and treated with packed red blood cell transfusion. She received three units and the next day felt much better.  She was discharged home.

No, the Inpatient admission was not medically necessary.
The patient in this case had severe anemia and definitely required packed red blood cell transfusion.  However, this did not require acute care inpatient admission. She had no hypotension and no significant ongoing bleeding. She could have been treated safely with transfusion without need for acute care inpatient admission to the hospital. The admission in this case was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As noted above, this patient required transfusion but did not require acute care inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, Low Blood Pressure.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a history of female transitioning, hypertension (HTN), multiple sclerosis (MS), and bipolar disorder who was admitted with complaints of (c/o) dizziness after seeing the primary medical doctor (PMD) and low blood pressure. The vital signs were significant for a blood pressure (BP) of 95/50. The physical exam was notable for no apparent distress (NAD). Lab work was notable for leukocytosis. A chest x-ray (CXR) showed no acute disease. The patient was diagnosed with hypotension rule out (r/o) sepsis and was treated in the emergency department (ED) with intravenous fluids (IVF) and IV antibiotics. Infectious disease (ID) was consulted and noted the patient had a chronic leukocytosis and recommended observing off of antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o dizziness after seeing the PMD and low blood pressure. The patient did not have associated high-risk features, such as acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, did not have pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient also did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. The patient was evaluated by ID and they recommended discontinuing antibiotics as the leukocytosis was chronic in nature. The patient presented with dizziness and low blood pressure, which responded to fluids, and ID consultation, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Prematurity Baby

Treatment: NICU (Neonatal intensive care unit) admission

The insurer denied coverage for NICU admission

The denial is modified

This case involves a newborn female who was born at 35 weeks gestation.  She was born due to her mother being induced due to preeclampsia.  She was noted to have intrauterine growth retardation (IUGR) with preeclampsia.  Documentation indicated she delivered an active and pink baby girl by normal vaginal delivery after being induced for labor due to preeclampsia/intrauterine growth retardation (IUGR).  The infant weighed 2.1 kg (kilograms) and was 44 cm (centimeters) in length.  The documentation indicated she was admitted to the intensive care unit for prematurity and impact of maternal diabetes (IDM).  The submitted documentation indicated the infant remained on room air and tolerated feedings.  She was noted to be clinically jaundiced.  At 53 hours of life, the bilirubin was 11.3.  Later that day her bilirubin was trending up to 12.5.  The following day she did remain stable, and her bilirubin had not increased.  She did undergo the car seat testing.  Throughout the entirety of the stay, there were no complications noted.  The infant remained stable and there were no adverse events.  She was discharged.

Late preterm infants are certainly at risk of hypoglycemia, jaundice, and feeding abnormalities and the testing an interventions done are appropriate. However, these did not require an intensive care unit (ICU) level of care. The infant's initial glucose checks (all normal) were not done more frequently than every 4 hours and should have been manageable in a floor setting. The infant had no indication of respiratory distress or hypothermia to prompt further monitoring. This child did not demonstrate a need for ICU-level observation or intervention. However, there are sources that recommend 12-24 hours of close observation for the mildly preterm infant, followed by rooming in with parent if stable. Therefore, the first day should be covered, while the following 2 days should be covered for floor care only.

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

The insurer's denial of coverage for an NICU is modified. Medical necessity is partially substantiated. Reverse the first day of admission and uphold the following days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bite on finger.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He sustained a fight bite to his left long finger. He was evaluated for wound check and found to have an infection. There was mild erythema to mid and proximal phalange. He had associated tenderness. There was concern for tenosynovitis.

The patient underwent an incision and drainage in the ED (emergency department). He was provided with IV (intravenous) antibiotics and received consultation by ID (infectious diseases) and Orthopedics.

No, the Inpatient admission was not medically necessary.
There was no indication for admission to hospital. The facts were the patient had a localized infection which was managed in the ED (emergency department). The ID (infectious diseases) consult was completed one day later and reported "switch to oral antibiotics." There was evidence of systemic disease.

The inflammatory markers were not elevated to suggest systematic involvement. There was no evidence of fever. There were no problems with pain. No special imaging studies were required. No other ancillary services were necessary. There were no findings to support necessity of inpatient care. The services could have been provided at an observation level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/circulatory problems.
Treatment: inpatient hospital.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

This is a case of a male admitted for diagnosis of left leg swelling and pain secondary to deep vein thrombosis (DVT). The patient presented with chief complaint of abnormal imaging. The patient experienced tightness of the leg when he was riding his bike to work. Vital signs demonstrated temperature 98.1F, pulse 81, respiratory rate 18, blood pressure 135/74 and O2 saturation 99%. Physical exam demonstrated no acute distress or altered mental status. The left calf had swelling and mild erythema but was nontender to palpation. White blood cell count was 4.9 with a hemoglobin 13.9. Platelets were 154,000 and chemistries were normal. International normalized ratio (INR) was 1.2 and troponin was negative. A Duplex ultrasound showed an acute deep vein thrombosis with occlusive thrombosis noted within the distal femoral vein, popliteal vein and gastrocnemius veins. The patient was treated with a heparin drip, and a hematology consult was requested. 

The inpatient stay was not medically necessary. The patient in this case had a deep vein thrombosis but did not have hemodynamic instability, history of prior bleeding episode, or renal insufficiency, The patient was able to be taught self-injection for anticoagulation and was able to be discharged home within a reasonable observation timeframe.
Although the patient had needs best addressed in the hospital setting the monitoring, the diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Surgery (broken jawbone)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

This patient is a male who suffered a traumatic injury that included facial lacerations
and fracture of the temporomandibular joint (TMJ) in a comminuted dislocated fashion. The patient had undergone initial stabilization surgery to include splinting of teeth and laceration closure. The patient's left condyle was dislocated and comminuted. The patient required admission along with open reduction and internal fixation to stabilize the trauma. The patient was initially evaluated at an outlying facility and when transfer was attempted the patient sought to take care of prior issues and then have surgery which is why the surgery was several days later.

Yes, the proposed inpatient hospital admission was medically necessary.

The treatment is to fixate a comminuted dislocated left temporomandibular joint (TMJ) fracture. For proper function, the fracture needs to be fixated. The inpatient hospitalization was necessary to assess for hemostasis as there are a number of large blood vessels in the surgical site. The following also needed to be closely monitored: airway, nutritional status, fluid status, pain control, post anesthesia nausea and vomiting. The patient's jaw was wired together and he could not open his mouth, so there are many inherent issues which is why the inpatient stay was utilized.

The health plan did not act reasonably, with sound judgement, or in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: Procedure to treat low back pain (procedure code 64628) Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral

The insurer denied coverage for procedure to treat low back pain (procedure code 64628) Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral. 

The denial is upheld.

This involves a male patient with worsening back pain with residual thigh pain. The magnetic resonance imaging (MRI) does reveal Lumbar (L) 2-3 moderate spondylosis with a disc bulge. There is a left foraminal disc protrusion at this level as well. Disc bulge at L3-L4 with spondylosis at this level as well as L4-5 and L5-Sacral (S) 1. At L5-S1 there was a disc bulge with severe spondylosis. On exam the patient is noted to have full range of motion with stiffness and pain in extremes of flexion extension. The pain does affect the patient's activities of daily living. The pain has failed nonoperative treatment and recommendation for the Intracept procedure was recommended.

The current scientific evidence and peer-reviewed literature does not support a result improvement in health outcome. At this time further studies need to be done to fully understand the long-term efficacy and risk profile this procedure exposes to patients. More high-powered quality randomized control studies with large sample size need to be submitted.

The procedure does not have final approval from the appropriate regulatory bodies for this diagnosis.     

The requested procedure needs to undergo further studies; therefore, this patient would not be a good candidate.     

The requested treatment is not the best available treatment for this patient.

Adverse risks in the long-term setting need to be studied.     

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of procedure to treat low back pain (procedure code 64628) Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral should be upheld.