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

Diagnosis: Cholelithiasis 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult with a past medical history significant for nephrolithiasis. The patient presented to the emergency room (ER) with complaints of fever and abdominal pain.

The patient was empirically started on intravenous (IV) antibiotics (Zosyn) for possible cholelithiasis. A computed tomography (CT) scan of the abdomen/pelvis showed left renal calculi and cholelithiasis. An abdominal ultrasound showed gallbladder wall thickening. Infectious Diseases was consulted for headaches and a lumbar puncture was recommended to rule out meningitis. The CT scan of brain was negative. Antibiotics were adjusted. The patient remained afebrile and hemodynamically stable. The patient decided to leave hospital against medical advice (AMA). 

According to medical record, the patient presented with complaints of fever, abdominal pain and severe headaches. The patient was febrile (102.7 Fahrenheit) and tachycardic (heart rate - 105). Laboratory abnormalities included elevated white blood cell count (WBC) 15.4 and alanine transaminase (ALT) 58. Based on above findings, in a patient with history recent international travel, hospital admission was medically necessary for administration of IV 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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis. 
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 
Acute cholecystitis and biliary complaints are common inpatient diagnoses. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase (ALP) and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. [9] 

Per clinical documentation, this patient presented to the emergency department with right upper quadrant and epigastric abdominal pain. Vital signs in the emergency department (ED) were within normal limits. The patient was afebrile. Abdominal ultrasound demonstrated cholelithiasis and was indeterminate for acute cholecystitis. Alanine transaminase (ALT) and aspartate aminotransferase (AST) were elevated to 111 and 86, respectively. White blood cell count was elevated at 12.0. The patient underwent a robotic-assisted laparoscopic cholecystectomy. There were no reported complications. There is no further clinical documentation of a need for inpatient admission. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation. [7] Peer-reviewed literature and MCG criteria indicate that inpatient admission is not 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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: growth hormone deficiency
Treatment: growth hormone
The insurer denied Skytrofa
The health plan's determination is upheld. 

This is a young male diagnosed with GHD (growth hormone deficiency). As reported, he has needle phobia. He started GH (growth hormone) therapy with Norditropin. He was started on 4.3 milligrams (mg) of Skytrofa. His GH stimulation test with arginine and L-dopa (levodopa) peaked at 7.9.

Skytrofa is not medically necessary.
Skytrofa has been shown to be safe and effective for the treatment of growth hormone deficiency. The study using the medication shows that the medication is clinically equivalent to daily injections of growth hormone in terms of efficacy and safety. The study showed a slight advantage of Skytrofa over daily somatropin but only went for 1 year and did not show improved final height. It has the advantage of being a weekly medication. Other than the convenience of weekly administration, the requested medication is not superior to daily growth hormone.
The patient is diagnosed with growth hormone deficiency. The patient was being treated with the daily growth hormone formulary alternative Norditropin with no documentation of failure. The patient can continue on the formulary alternative Norditropin or try Genotropin. The request does not meet the standard of care and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.

The patient is a female. She has a 2 millimeter (mm) overjet and 2mm overbite. She presented with a Class I malocclusion and a posterior crossbite on the left. She has a mandibular deviation to the left. She has moderate crowding. She is treatment planned for orthodontics with rapid palatal expansion (RPE) to correct her malocclusion and crossbite. At issue is the medical necessity of braces.

There is strong medical evidence that that early correction of unilateral posterior crossbites with a shift reduces the need for future treatment. This patient presented with a posterior crossbite, crowding, and constricted arches. She would be an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Orthopedic expansion as part of orthodontic therapy can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. (2) Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: melena
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 gastroesophageal reflux disease (GERD), peptic ulcer disease, hypertension, hyperlipidemia, diabetes mellitus type II, coronary artery disease status post stent placement, aortic valve repair, carotid stenosis, and cerebrovascular accident. He presented to the emergency department with melena. 

The inpatient hospital admission was not medically necessary, and the care provided could have been provided at a lower level of care. In this case, the patient presented with anemia and melena. His blood count remained stable, and he did not have hypotension or hemodynamic decompensation. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. He appropriately had an esophagogastroduodenoscopy to evaluate for sources of gastrointestinal bleeding, and although gastric ulcers were found, no active bleeding was reported, and there were no documented high-risk stigmata. He was appropriately treated with proton pump inhibitor therapy. Colonoscopy did not show active bleeding or high-risk findings. All of the measures that were undertaken, including monitoring, labs, Gastroenterology consultation, proton pump inhibitor therapy, and endoscopic procedures, could have been performed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The insurer denied intraosseous basivertebral nerve ablation. 
The determination is upheld. 

This is a male patient with chronic low back pain. He has had complaints of low back pain with bilateral, left more than right radiation for the past 7 plus (+) years. He has tried lumbar epidural steroid injections. He has had near complete relief of back pain following transforaminal lumbar epidural steroid injections. 
Magnetic resonance imaging (MRI) of the lumbar spine shows multilevel degeneration. It appears there are Modic type 1 changes in lumbar (L)3, L4, L5, sacral (S) 1 vertebral bodies, however, images are not available from medical records to confirm. This is based off record review. The suggested diagnosis is vertebrogenic low back pain. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

According to guidelines and cited references, despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. There should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between L3 and S1 on magnetic resonance imaging. 
According to Becker, et.al : "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)." 
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. 
As cited above, the Becker. et.al trial indicated only a 17 patient observational study.
These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. 
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. In addition, no United States (U.S.) guidelines based on research recommend this treatment. As such, the proposed health service or treatment Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The insurer denied intraosseous basivertebral nerve ablation. 
The determination is overturned. 

The patient is a male with a history of chronic low back pain. A magnetic resonance imaging (MRI) scan of the lumbar spine revealed disc degeneration, disc displacement, Modic changes and facet arthropathy. He as treated with lumbar epidural injections and medical marijuana. His treating provider has suggested Intraosseous basivertebral nerve ablation. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The proposed health service or treatment Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. A review of available up-to-date publications utilizing  basivertebral nerve (BVN) ablation in the treatment of vertebral pain suggests that there is quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to evidence that BVN radiofrequency ablation (RFA) is superior to conservative care for pain reduction, at least at 3-month follow-up. Also there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious adverse events (AEs) based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The insurer denied intraosseous basivertebral nerve ablation. 
The determination is upheld. 

This is a male patient with chronic low back pain. Prior treatments have included medications, injections, as well as medical marijuana. The pain remains severe and severely impacts activities of daily living (ADLs). Magnetic resonance imaging (MRI) of the lumbar spine showed Modic type I changes lumbar (L) 3-4, L4-L5, L5-sacral (S)1. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The proposed health service or treatment intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Throat pain.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The patient is a male, who presented with throat pain and inability to tolerate oral intake. He was well until several weeks prior to presentation when he developed a sore throat, conjunctivitis, periorbital swelling, and a decreased appetite. He also had decreased urine output. He was seen in the emergency department and was sent home after fluid rehydration. However, he returned several days later with similar symptoms and persistent fever. His temperature was up to 103.5 F (Fahrenheit). At that point, laboratory values were obtained, which revealed Epstein-Barr Virus infection. He also had elevated inflammatory markers and transaminitis. He was prescribed clindamycin and was sent home again. However, he returned a third time with continued throat pain, drooling, and difficulty speaking, and again had an evaluation performed.

Inpatient Hospital Admission was medically necessary for this patient.

This is a teenage boy, who presented after several emergency visits with persistent throat pain and difficulty swallowing. He had received appropriate evaluation and treatment as an outpatient, but his symptoms continued to worsen. At the time of presentation, he was unable to drink, was drooling, and had elevated inflammatory markers. He therefore required hospital admission for ongoing care including parenteral antibiotics, pain control, and intravenous fluids.

The decision making at the time of admission for this patient was consistent with his ongoing illness, despite multiple visits to the emergency department, the presence of significant discomfort and an inability to maintain his hydration status, and the need for ongoing treatments with antibiotics, pain control, and fluids along with close monitoring for potential deterioration of clinical status.

Patients require admission for intravenous rehydration therapy if they have an inability to take oral rehydration therapy or if oral rehydration therapy would not provide adequate hydration. This patient had been unable to drink for multiple days and was drooling and had an infection that required fluid hydration. Therefore, the inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left foot ulcer
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
 
Adult patient with past medical history significant for diabetes mellitus, gastroparesis, and polycystic ovarian syndrome (PCOS) who presented to the emergency department (ED) with complaints of left foot ulcer. 

Vital signs on presentation included: Temperature 99.5 Fahrenheit, Blood Pressure 145/90, Pulse 115, Respiratory Rate 21, oxygen (O2) saturation 96% on room air. Laboratory results were: White blood cell count (WBC) - 08.3, hemoglobin (Hgb) -11.1, Hct -36.4, creatinine -1.64, glucose -76.

The patient was started empirically on intravenous (IV) antibiotics for possible right foot infection. Radiographic image (x-ray) showed irregularity of skin and superficial soft tissues at the plantar heel consistent with ulcer. Magnetic resonance imaging (MRI) of the foot showed non-specific mild patchy marrow edema in the fifth metatarsal base. Infectious Diseases recommended continuation of antibiotics. Patient remained afebrile, hemodynamically stable, and was discharged to continue outpatient management. 

According to medical records, patient returned to the hospital for worsening left foot infection. Otherwise, patient was afebrile, hemodynamically stable. Laboratory results were unremarkable, including a normal WBC. MRI was negative for osteomyelitis. Patient had no evidence of disseminated infection and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management.

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: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of hypertension, hyperlipidemia, and coronary artery disease with a left ventricular ejection fraction (LVEF) of 40 percent (%) who had recently declined intervention. He was admitted for an elective catheterization. He was having chest pain exacerbated by stress and had an abnormal exercise test. His vital signs were essentially normal. He underwent successful intervention of a left anterior descending (LAD) and marginal artery stenosis. He remained stable and was discharged. At issue is the medical necessity of an inpatient stay.
This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting an inpatient level hospitalization, compared to for example observation or outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spotting and abdominal cramping
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the ED emergency department) with vaginal spotting and pain. She had been seen at Planned Parenthood the day prior and had an elevated HCG (Human Chorionic Gonadotropin) level, but no intrauterine pregnancy. She arrived at the ED (emergency department) and had examination, blood work, and ultrasound.
No pregnancy was identified. The patient was admitted and observed. She was given fluids and pain medication. She was evaluated by Gynecology, and repeat ultrasound was obtained. This revealed a 4.2 centimeter echogenic adnexal mass. She was taken to the OR (operating room). She had a suction D&C (dilatation and curettage) however no villi were identified by pathology. Because of that, a laparoscopy was performed. An ectopic pregnancy was identified in the right tube. The patient underwent a salpingectomy. She was transferred to recovery and was able to go home later that same day. The inpatient hospital stay has been denied coverage by the health plan as not medically necessary. This is being appealed.

The inpatient admission was not medically necessary.

According to ACOG (American College of Obstetricians and Gynecologists), "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 [enhanced recovery after surgery] pathways has resulted in more rapid surgical recovery, shorter length of stay, greater patient satisfaction, and decreased costs 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 [enhanced recovery after surgery] program requires collaboration from all members of the surgical team. Successful ERAS [enhanced recovery after surgery] 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 [enhanced recovery after surgery] pathways should be strongly encouraged within institutions."
An outpatient/ambulatory observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management. 
It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient. The patient in question was taken to the operating room and underwent an uncomplicated procedure for an ectopic pregnancy. After surgery she was transferred to recovery and reached appropriate milestones and was discharged the same day. Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided at a lower level of care.