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



Diagnosis: Substance Abuse/Addiction/Alcohol Abuse with Intoxication, Unspecified.
Treatment:  Alternate Level of Care (ALOC) stay.
The health plan denied the requested Alternate Level of Care (ALOC) stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for alcohol use disorder, generalized debility and gait dysfunction. He was admitted to skilled care after an acute hospitalization for alcohol withdrawal. 
At issue is the medical necessity for the requested health service/treatment of an alternate level of care (ALOC) stay.

No, the requested health service/treatment of an alternate level of care (ALOC) stay was not medically necessary for this patient.
The patient is a male admitted to the emergency room to acute care hospitalization secondary to alcohol use disorder with intoxication and withdrawal. The patient was stabilized in the hospital and was subsequently sent to rehabilitation for skilled care with physical and occupational services.
It is noted that the patient was able to ambulate and was also able to independently perform most activities of daily living (ADLs). Physical therapy notes document that the patient was able to ambulate up 12 steps with minimal assistance and the patient was able to ambulate safely to 200 feet with contact guard assist (CGA).
The patient was not receiving any other skilled services such as intravenous antibiotics or medical treatments.
The patient was in skilled services for almost 2 months. He did regain function with an ability to ambulate and perform most ADLs with minimal assistance. The patient had ongoing cognitive deficits secondary to brain injury and alcohol use. However, the services being provided did not necessitate ongoing inpatient skilled services. Services could have been provided in an alternate location. There were no noted other skilled services being performed which would necessitate ongoing inpatient skilled services. Services being provided would have been considered custodial in nature and not skilled.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is: Upheld

The patient is a female with complaints of low back pain. The patient's diagnoses include spondylosis without myelopathy or radiculopathy lumbosacral region. The patient has trialed and failed conservative treatment. There is a request for Intracept procedure. The subject under review is the medical necessity for the Intracept procedure for this patient.

The health plan's determination is upheld.

The Intracept procedure is not medically necessary. 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 requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: D8080-Braces
The insurer denied: D8080-Braces
The denial is overturned

The patient is an adolescent male with a Class I malocclusion. He has mild upper crowding and moderate lower crowding. There is a deep bite and impacted lower second molars. The patient has an anterior crossbite between teeth #'s 7 and 27. 
The prior denial was due to the score being 17 on the Handicapping Index Scale.

The proposed treatment is medically necessary.

The patient has a Class I malocclusion. He has mild upper crowding and moderate lower crowding. There is a deep bite and impacted lower second molars. The patient has a crossbite of two permanent anterior teeth (#7 and #27) with gingival (gum) attachment loss. This is an automatic qualifier according to the Handicapping Index Scale.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain, nausea and diarrhea.
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

This patient is an adult female, who presented to the emergency department with the complaint of abdominal pain, nausea and diarrhea. Comorbid health conditions included thalassemia and a history of thyroid carcinoma status post thyroidectomy. The patient's examination revealed right lower abdominal tenderness. Vital signs identified a normal temperature and normal vital signs at the time of presentation. The white blood cell (WBC) count was normal at 9.6 thousand (K). Surgical consultation was obtained. Computed tomography scan was completed showing findings of acute appendicitis. The patient was started on intravenous antibiotics. The patient underwent laparoscopy with appendectomy for the condition of appendicitis that was performed on the night of admission. The operative note describes findings of nonperforated appendicitis. Following surgery, the patient was treated with intravenous fluid and analgesia. Vital signs were consistently normal in the perioperative period. She was transitioned to oral medications and diet. She remained stable in the post-surgical period and was discharged from the hospital on the next day.

The health plan rationale for denial per the denial letter is that there is no documentation of need for an inpatient level of care, and the care rendered could have been provided without admission to the hospital.

The proposed inpatient hospital admission was not medically necessary.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with a lower level of care during this period of time. This patient presented with abdominal pain. The evaluation with examination, lab data, and computed tomography scan supported the diagnosis of acute appendicitis. The patient underwent uncomplicated appendectomy. She was admitted to an inpatient level of care and was discharged from the hospital on the first post-surgical day. There is no clinical documentation to support need for inpatient admission on these dates. The patient remained hemodynamically stable throughout the perioperative period, there was no documented complication of surgery. This patient's clinical needs could have been satisfied without need for an inpatient designation and could have been satisfied with a lower level of care. This lower level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation (if required). The records support that the care provided was clinically appropriate. It is the level of care (inpatient versus outpatient / observational) that is at issue in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain	

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

 
This was an adult patient that presented to the hospital complaining of chest pain. The chest pain radiated to the left jaw and was associated with dyspnea and palpitations. Past medical history was significant for heart failure with reduced left ventricular ejection fraction, left ventricular apical thrombus, sick sinus syndrome and permanent pacemaker, hypertension, and stroke. The patient noted that his symptoms were relieved once he entered an air-conditioned ambulance. He reported running out of medication three days prior to symptom onset. On arrival to the hospital, vital signs were stable (blood pressure (BP) 119/84, Pulse 88). Physical examination revealed no major abnormality. A 12-lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST (interval on an ECG) or T wave (interval on an ECG) abnormalities. Serum troponin levels were not elevated (< (less than) 0.01 nanograms per milliliter (ng/ml)). The patient was treated with oral medication and discharged with cardiology follow up.

This patient presented with atypical chest pain and a past medical history of hypertension. His pretest probability of coronary artery disease was intermediate. Utilizing the HEART (History, Electrocardiogram [ECG], Age, Risk factors, and Troponin) score he was considered low risk. Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Risk assessment of patients presenting with chest pain and no significant ST changes on an ECG was reviewed by Hedayati et al. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small fiber neuropathy
Treatment: Intravenous Globulin (IVIg)
The health plan denied Intravenous Globulin (IVIg).
The health plan's determination is upheld.

The patient is a female with a diagnosis of small fiber neuropathy. The patient also has Sjogren like symptoms, autonomic dysfunction and joint hypermobility. 

The available studies do not support the use of intravenous immunoglobulin to treat small fiber neuropathy. The peer reviewed literature has two controlled trials that examine the use of intravenous immunoglobulin to treat small fiber neuropathy. In the first trial, intravenous immunoglobulin is compared to the placebo for the treatment of idiopathic small fiber neuropathy. The results of this trial show that there is no difference between intravenous immunoglobulin and the placebo for the treatment of the symptoms related to small fiber neuropathy. There were no significant differences found on any of the other prespecified outcomes, including general well-being, autonomic symptoms and overall functioning and disability.

In the second available randomized controlled trial, intravenous immunoglobulin was compared to the placebo for treatment of small fiber neuropathy with trisulfated Heparin Disaccharide (TS-HDS) and fibroblast growth factor receptor 3 (FGFR-3) autoantibodies. In this study, patients with small fiber neuropathy (SFN) did not detect a benefit in the treatment of IVIG compared to treatment with TS-HDS and FGFR-3 autoantibodies. In the only available controlled studies, there was no difference between treatment with the placebo or intravenous immunoglobulin. In a retrospective analysis of patients, one study concluded that there is proof-of-concept evidence suggesting that IVIG is safe and effective for rigorously selected small-fiber polyneuropathy (SFPN) patients with apparent autoimmune causality. This study was not placebo controlled and called for further research on the topic.
Currently, the available evidence does not favor the use of intravenous immunoglobulin for treatment of small fiber neuropathy although nearly all studies call for further controlled studies to be performed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

 
This patient has a past medical history of renal stones, hypertension, and obesity. The patient presented to the emergency department with left lower quadrant abdominal pain radiating to the lower back. The patient was admitted for further evaluation of left flank pain and stones. The patient was taken for cystoscopy with placement of a double J stent (ureteral stent) and a moderate amount of old blood returned. The patient was stable for discharge home on oral Keflex and an outpatient follow up for further stone treatment. 

Per Milliman Care Guidelines Health (25th) Edition for Renal colic and Kidney stones - the patient fails to meet clinical indications for admission to inpatient care. Under Urologic surgery or Procedure GRG (General Recovery Care guidelines) - the patient meets the GRG discharge parameter within 24 hours postoperative.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for a full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stones. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is a patient with past medical history of alcohol abuse, hypertension, anemia, prostate cancer status post radical prostatectomy, and diabetes mellitus. The patient presented to the emergency department for left flank pain and persistent vomiting. Evaluation in the emergency department with a computed tomography scan (CT) showed left hydroureteronephrosis due to a 1.5 x 0.7 cm (centimeter) proximal left ureteral stone and non-obstructing left lower pole stones. The patient was admitted, seen by urology, made NPO (nothing to eat or drink by mouth), and taken to the operating room for a cystoscopy and a left stent placement. The patient tolerated the procedure well without complications, recovered well, and was discharged home. 

Per Milliman Care Guidelines (MCG) Health: Renal colic and kidney stones - the patient fails to meet clinical indications for an admission to inpatient care. Under the urologic surgery or procedure GRG (General Recovery Care guidelines) - the patient meets the GRG discharge parameter within 24 hours postop. 

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

Diagnosis: Pilonidal cyst in the sacral region
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is young adult with a past medical history significant for diabetes mellitus, asthma, depression, attention deficit hyperactivity disorder, and morbid obesity who presented to the emergency room with complaints of a painful cyst in the sacral region. 

Vitals on presentation included: Temperature 98.0 degrees Fahrenheit, Blood Pressure 126/77, Pulse 82, Respiratory Rate 17, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory results included the following: white blood cell (WBC) count 11.8, Hemoglobin (HGB) 14.5, Hematocrit (Hct) 43, creatinine-0.7, glucose-95.

The patient was started empirically on intravenous antibiotics (clindamycin) for a pilonidal cyst.

Surgery was consulted for removal of cyst. Procedure was uncomplicated. Patient remained afebrile, clinically, and hemodynamically stable. He was discharged to continue outpatient management.   

According to documentation, the patient presented with a chronic pilonidal cyst to his sacral area. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory results including a minimally elevated WBC. Patient had no evidence of a disseminated infection. Based on above, patient was stable for outpatient management.     
  
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: New onset atrial fibrillation

Treatment: Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacological induced stress, with interpretation and report, code 93350

The insurer denied echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacological induced stress, with interpretation and report, code 93350.

The denial is overturned.

This is an adult male who presented with complaints of palpitations and shortness of breath. Symptoms correlated with new onset atrial fibrillation recorded by Apple watch. Past medical history was significant for obstructive sleep apnea. Examination revealed mild hypertension [blood pressure (BP) 146/70] and no other abnormalities. The patient underwent exercise stress echocardiography.

According to the medical records, this patient had atrial fibrillation with ventricular rates greater than 100 and accompanying symptoms of dyspnea and chest discomfort. His pretest probability of significant coronary disease is intermediate. [1] The Framingham Heart Study noted a clear link between paroxysmal atrial fibrillation and coronary disease. [2] American Heart Association (AHA) guidelines recommend noninvasive testing for such patients. [3] Appropriate use criteria deem stress echocardiography to be an appropriate diagnostic test for such patients. [3] In conclusion, stress echocardiography was medically necessary in this patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacological induced stress, with interpretation and report, code 93350, is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis. 
Treatment: Dupixent (dupilumab). 

The insurer denied coverage for Dupixent (dupilumab). 

The denial is overturned. 

The patient is a young adult with a diagnosis of severe atopic dermatitis affecting 30% total body surface area (TBSA). The patient has failed multiple therapies, including Adbry. The patient was previously treated with some success with weekly Dupixent.  The medical plan was to discontinue Adbry and re-initiate Dupixent with 3x/week Narrow-band ultraviolet B (NB-UVB) therapy. The request is for approval of dosing of Dupixent to be weekly. 

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary.  The patient has tried and failed multiple therapies, including Adbry and Dupixent biweekly.  In 2019, Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases." in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1).  Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2).  The patient's disease is refractory to multiple medications necessitating the clinical addition of NB-UVB therapy in addition to the weekly Dupixent dosing.  Therefore, it is appropriate, based on the patient's clinical findings and refractory disease, to approve weekly Dupixent in this patient. 

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 Dupixent (dupilumab) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain.
Treatment: Pain Management Injections.
The health plan denied: Pain Management Injections.
The health plan's determination is overturned.

This patient has low back pain and right lower extremity pain. She reported sharp shooting pain in the right leg. She had tried pain medications, physical therapy (PT), and chiropractic manipulation without improvement. Her pain is severe with functional impairment. The physical exam revealed positive straight leg raise test on the right. She previously underwent right L5 and S1 transforaminal epidural steroid injection with 12 months of pain relief. Magnetic resonance imaging (MRI) showed grade 1 anterolisthesis L5 on S1 with severe bilateral foraminal stenosis.
At issue is the medical necessity of the requested health service/treatment of pain management injections.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of pain management injections is medically necessary for this patient.
This patient has back pain and radicular pain from her L5 on S1 anterolisthesis and foraminal stenosis. She had failed conservative treatments including pain medications, PT, and chiropractic manipulation. The prior L5 and S1 transforaminal injections provided her with 12 months of pain relief. Her pain is severe with functional impairment. Further treatments are medically necessary to improve her pain and function. The alternative is L5/S1 lumbar decompression and fusion, which is a major spine surgery associated with serious risks and complications. Given this clinical scenario, the requested right L5 and S1 injections are the appropriate next step intervention.