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

Diagnosis: Low Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied: Intraosseous basivertebral nerve ablation 
The denial is: Upheld.

This is a male who has a long history of chronic back pain. His pain is increased by bending and twisting motion of the lumbar spine and also increased by prolonged sitting. Physical exam revealed tenderness to palpation in the lumbar region with negative facet loading test and negative straight leg raise test. A magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease with Modic changes at (lumbar-sacral) L5-S1, annular tear at (lumbar) L4/5 level, and foraminal stenosis at L4-5 and L5-S1 levels with impingement of bilateral L4 and L5 nerve roots. The patient had tried a lumbar epidural steroid injection with minimal improvement. He is on opioid medications for his chronic pain. For his persistent back pain he was recommended to have an Intracept procedure.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

No. The Intraosseous nerve ablation procedure (Intracept ) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This intervention is offered to patients who failed prior conservative treatments including physical therapy. However, this patient has not tried physical therapy for his back pain. Physical therapy should be attempted to improve this patient's pain prior to the consideration of the Intracept procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tinnitus, Ear Pain
Treatment: CT scan
The insurer denied the CT scan.
The determination is overturned.

This is a female patient with a history of tinnitus and ear pain. In attempting to fully evaluate the patient, her provider felt that it was in the patient's best interest to determine if there were any temporomandibular (TM) joint problems that could be causing her ear pain and tinnitus. At issue is the medical necessity of a computed tomography (CT) scan.

Yes, the requested health service is medically necessary.
The patient has a documented diagnosis of tinnitus and ear pain. Her provider felt that it would be in her best interest to see if some of her problems could possibly be related to a TM joint problem. The patient saw an oral and maxillofacial surgeon (OMS) who determined that cone beam computed tomography (CBCT) imaging was necessary to fully evaluate the joint. This type of imaging is well within the standard of care and would allow the OMS provider to determine if there were any craniofacial abnormalities or old mandibular fractures.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Shoulder Pain
Treatment: current procedural terminology (CPT) code 97026 x (times) 5
The insurer denied coverage for current procedural terminology (CPT) code 97026 x 5.
The denial is upheld.

The insurer denied coverage for 5 visits of acupuncture treatment with infrared heat. The denial is upheld. This is an adult patient with a diagnosis of severe 8 out of 10 (pain scale 0 to 10) right shoulder pain. The patient had right shoulder rotator cuff repair surgery. According to provided clinic notes, treatment has included over the counter (OTC) pain-relievers, chiropractic manipulation treatments, ice therapy treatments, and herbal analgesic ointment. Medical Necessity Review (MNR) was performed by American Specialty Health Group (ASHG). ASHG approved 8 office visits and 16 therapies. The MNR form clearly states that MNR is not a guarantee of payment; final payment is subject to group benefit limits and member eligibility. The MNR form also stipulates that the treatment plan may be supported when all of the following are met: 1) your complaints, exam findings, and diagnoses correlate with each other; 2) it is supported by the nature and severity of your complaints; 3) it is supported by your exam findings; 4) expected to improve your symptoms (such as pain, function) within a reasonable period of time; and 5) requires the skills of your provider. The records provided do not support these guidelines. Severe 8/10 pain with a history of prior surgery should receive a complete medical evaluation. The clinician should first distinguish between extrinsic and intrinsic causes before establishing a treatment plan. 
Centers for Medicare and Medicaid Services (CMS) has determined that CPT code 97026 (infrared therapy) is noncovered for all indications. UpToDate makes no mention of the use of infrared heat therapy for the treatment of severe shoulder pain. There is no evidence in the medical literature that infrared light therapy is any more effective than other heat modalities in the symptomatic relief of musculoskeletal pain. The article submitted by the appealing provider, Infrared Radiation in the Management of Musculoskeletal Conditions and Chronic Pain: A Systematic Review, concluded that while infrared (IR) appears to be a safe and effective complementary therapy for some musculoskeletal conditions, its efficacy remains debatable. This review article states that further research is necessary in order to establish the optimal indications and treatment plan for the clinical use of IR in musculoskeletal medicine. The authors also note that the included studies had several limitations. The limited sample size (only 13 patients in one study), in combination with the lack of long-term follow-up, casts doubt on the real-world significance of the reported outcomes. 
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 current procedural terminology (CPT) code 97026 x 5 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope (during pregnancy)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult female with 3 pregnancies, 2 full term deliveries, and 2 living children (G3P2002) who was admitted from the clinic for a history of two syncopal episodes and possible gastroenteritis and hypovolemia. Subsequent to one of these episodes, the patient developed a headache. She had previously been worked up in the pregnancy for palpitations with Holter monitor, electrocardiogram (EKG), and cardiology consultation. Workup was done for direct complications of pregnancy which was unremarkable. Due to the persistence and severity of the headache, which she rated as ten out of ten (10/10), an extensive workup was done including magnetic resonance angiogram (MRA), magnetic resonance venography (MRV), and neuro-ophthalmology. A neurology consultation was obtained that recommended a lumbar puncture be performed. However, this was unsuccessful after multiple attempts. The patient was subsequently taken to interventional radiology where a successful lumbar puncture was performed revealing elevated opening pressure consistent with idiopathic intracranial hypertension. The patient was started on acetazolamide and her symptoms improved and she was discharged home undelivered. 
The health plan contends that the admission was not medically necessary because there were no medical conditions that met InterQual criteria for inpatient level of care and cites InterQual 2021 Release, Level of Care: Acute Adult, General Medical, Neurological. The facility contends that the admission was medically necessary due to a high probability of imminent or life-threatening deterioration and cites Milliman Care Guideline ORG: M-185 Headaches, which states that admission is indicated for one or more of the following: Severe headache that persists despite observation care, increased intracranial pressure, or intravenous fluid required.

The proposed treatment was medically necessary.

Although headaches are common during pregnancy, there are uniquely hazardous etiologies of headaches that are either specific to or more likely to occur during pregnancy. These include headaches due to thrombotic events such as cerebral venous thromboses, posterior reversible encephalopathy syndrome, severe preeclampsia, intracranial hemorrhage, cervical artery dissection, idiopathic intracranial hypertension, pituitary apoplexy, and reversible cerebral vasoconstriction syndrome. For these reasons, it is more important and time sensitive to determine the etiology of headache during pregnancy compared to the non-pregnant state, especially when it is new onset and severe. There was also delay in the workup of this patient which was unavoidable due to difficulties with direct performance of the lumbar puncture that necessitated performance of the procedure using interventional radiology techniques. Therefore admission, and admission of this duration, was necessary to expedite the workup and treatment of this patient's headache.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This child presented to the Emergency Department (ED) due to facial swelling and dental pain. The patient had visited a dental clinic (no documentation of date) x-ray was done with negative results and was prescribed amoxicillin as an outpatient. The patient took one dose of amoxicillin and then was seen at urgent care clinic (no documentation of date) and then was sent to emergency room (ER). 

In the ER the patient had a temperature of 101.5 degrees Fahrenheit (F), increased heart rate to 140, edema, erythema, tenderness of the maxillary region extending to the lower eyelid with warmth to the area, and dental pain noted. Labs revealed leukocytosis of 15.8 with neutrophil predominance of 77.4 and elevated erythrocyte sedimentation rate (ESR) of 23 and C reactive protein (CRP) of 10.3. The patient was admitted to the Pediatrics unit for facial cellulitis vs (versus) dental abscess and received intravenous (IV) antibiotics and close monitoring. During discharge the patient was stable to follow up with Pediatric dental clinic.

Based on the information provided, the patient did not have conditions to meet inpatient admission criteria. The patient was not unstable. Observation level of care criteria was met. 

Per Milliman Care Guidelines (MCG) criteria "Cellulitis Pediatric" inpatient admission criteria includes the following:

1)	Unstable vital signs that did not improve - Criteria NOT MET 
2)	Evidence of infection that spread to blood - Criteria NOT MET
3)	Limb-threatening infection with high pressures (compartment syndrome) - Criteria NOT MET
4)	Failure of outpatient treatment - Criteria NOT MET
5)	Gum/mouth (buccal infection) without adequate vaccination against Hemophilus Influenzae type B - Criteria NOT MET

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: Chronic Obstructive Pulmonary Disease
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult female with chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and human immunodeficiency virus (HIV). The patient presented to emergency room (ER) with worsening shortness of breath (SOB) and dyspnea on exertion (DOE). The patient was found to be in chronic obstructive pulmonary disease exacerbation. The patient was admitted to acute in-hospital level of care for the management of chronic obstructive pulmonary disease exacerbation. The patient was treated with oral prednisone, Zithromax, intravenous (IV) fluids and bronchodilators. The acute in hospital admission was denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was not medically necessary.

The patient was admitted to acute in-hospital level of care for chronic obstructive pulmonary disease exacerbation. At the time of admission, the patient was hemodynamically stable. The patient was not in severe respiratory distress. The patient's 
respiratory status had improved with emergency room care. The patient was able to ambulate and tolerate oral diet. The acute in hospitalization was not medically necessary. Since the patient's signs and symptoms improved significantly with emergency room 
care, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment provided in this patient was reasonably expected to be provided but does not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is a toddler boy with medical history of eczema and food allergies. He presented to the emergency room with continued vomiting after having been admitted 4 days earlier with vomiting and diarrhea. Per the patient's mother, the vomiting had persisted, occurring about three times a day. 
The patient presented with pallor and seemed tired in the emergency room. Vital signs revealed a heart rate of 132 and blood pressure of 103/52. Laboratory evaluation was significant for a bicarbonate of 13 and creatinine 0.54, with a blood urea nitrogen (BUN) of 8. The patient was admitted for continued symptoms of acute gastroenteritis. He was given intravenous fluid boluses followed by maintenance intravenous fluid at a rate of 1.5 times the usual maintenance rate. A stool pathogen panel was negative. The patient was given medication to facilitate stooling and afterward, had improved abdominal distention. His laboratory evaluation improved with the fluids, as did his clinical presentation. He was allowed to be discharged home the day after admission.

The proposed inpatient hospital admission was not medically necessary.

The patient presented with signs of dehydration due to persistent symptoms of an acute gastroenteritis - elevated heart rate, dry mucous membranes, and a bicarbonate of 13. However, the patient had fewer symptoms than his previous admission, indicating that the infection was likely beginning to wane despite his persistent symptoms. His glucose was within normal limits, indicating that his oral intake was sufficient to prevent hypoglycemia. He did not have abdominal tenderness on exam, nor did he have fever - both of these being signs of a more serious disease process. As well, it was documented that he had been taking some oral intake at home, indicating it would have been reasonable to admit the patient in observation status in order to correct his acutely dehydrated state, in anticipation of allowing further/continued oral rehydration at home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, rheumatoid arthritis, and depression
Treatment: 8 hours/day, 7 days/week, total of 56 hours/week Personal Care Services (PCS), level 2
The insurer denied coverage for 8 hours/day, 7 days/week, total of 56 hours/week PCS, level 2.
The denial is upheld.

This is a geriatric patient with hypertension, rheumatoid arthritis, and depression. The patient lives with the spouse in a private residence. The insurer approved Personal Care Services (PCS) level 2, 5 hours/day, 7 days/week, totaling 35 hours/week. Under review is the request for PCS level 2, 8 hours/day, 7 days/week, totaling 56 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. The patient is safe in the home if left alone and able to call 911 in case of emergency. The patient requires maximal assistance for much of the instrumental activities of daily living (IADLs) including meal preparation, ordinary housework, and shopping. However, only limited assistance is needed for bathing, personal hygiene, dressing, locomotion, toilet transfer/use, and ambulation (uses a walker). The patient is independent with bed mobility and eating. The patient is frequently incontinent of bladder and continent of bowel. The functional ability has improved and there have been no reported falls over the prior 90 days. The functional ability is also much improved when compared to the previous UAS report.

The patient's condition and functional needs are not at a level or unpredictable as to require the requested PCS 8 hours/day, 7 days/week, totaling 56 hours/week. This physician would agree. The patient may require additional monitoring, primarily due to overall safety concerns, given the reported general weakness. However, safety monitoring under PCS does not include monitoring an individual when no other level 1 or level 2 PCS task is being provided. Aides do not manage behavior or medical conditions. As noted by the insurer, PCS for companion care or safety supervision without the direct provision of activities of daily living (ADLs) is not a covered service. Based on the enclosed documents reviewed, the patient's health and safety, particularly as it relates to IADLs and ADLs, are appropriately provided and maintained at home by the currently approved PCS 5 hours/day, 7 days/week, totaling 35 hours/week.

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 8 hours/day, 7 days/week, total of 56 hours/week PCS, level 2 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth
Treatment: Tooth Colored Cap with Metal Underneath (Crown) for Teeth #'s 4 and 30
The insurer denied: Tooth Colored Cap with Metal Underneath 
(Crown) for Teeth #'s 4 and 30
The denial is overturned

This case involves an adult female who is appealing the denial of coverage of crowns on teeth #4 and #30. The initial review denied treatment due to the fact there are at least four upper and four lower teeth that occlude together. Teeth #4 and #30 have previous endodontic treatment.

The proposed treatment is medically necessary.

Teeth #4 and #30 have previous endodontic treatment and require cuspal coverage. Tooth #14 is not considered to be in occlusion. There may be a small portion of tooth #14 occluding with tooth #18, but it is hardly a functional occlusion. Therefore, the criteria used to deny the crowns based on the number of teeth in occlusion does not apply. Crowns are medically necessary for teeth #4 and #30.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Other-Dizziness
Treatment: Inpatient Admission
The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld.

This patient is a male who presented with dizziness for 3 weeks. His history was significant for hypertension, and subclavian stenosis with stent placement 3 weeks prior. He had been evaluated for dizziness previously and started on Meclizine. He was hemodynamically stable, afebrile, not hypoxic, and was tolerating oral intake. An electrocardiogram (EKG) showed sinus rhythm without evidence of acute ischemia. A computed tomography angiography (CTA) of the head/neck showed no significant acute abnormalities. Labs were significant for a sodium of 130, and a chloride of 95. The emergency department (ED) physician treated him with Metoclopramide, Acetaminophen, and Meclizine. A cardiologist recommended follow up with neurology for vertigo.
The next day he was clinically stable. The admitting physician continued Meclizine. A neurologist diagnosed "likely peripheral vertigo" and recommended a magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of the head/neck.
For the next date of service, there were no submitted physician notes. A critical lab value report is included, indicating a low calcium level and an order for intravenous (IV) calcium supplementation.
The patient was discharged. The MRI/MRA head/neck showed no significant abnormalities, and an MRI of the cervical (C)-spine showed no significant abnormalities.
At issue is the medical necessity for the inpatient admission.

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

The requested treatment of inpatient admission was not medically necessary for this patient.
This patient was evaluated and treated for ongoing dizziness which had been worked up 3 weeks prior. He had no hemodynamic instability, severe or persistent altered mental status, respiratory failure, arrhythmia of immediate concern, inability to tolerate oral intake, and he did not require or receive any treatment that can only be delivered at the inpatient level of care. In the absence of instability his treatment could have been delivered at an alternate level of care without incarcerating the patient in the hospital for 3 days.
Current medical literature supports outpatient delivery of workup and treatment of peripheral vertigo. During this hospital visit this patient's treatment, including Meclizine, consultation with specialists, and imaging studies, could have been delivered in the outpatient setting. There was no evidence of clinical instability or high risk causes of dizziness to support medical necessity of inpatient admission. The treatment could have been delivered at an alternate level of care.