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

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

This is the case of an adult male who presented to the emergency department (ED) with the complaint of left lower quadrant (LLQ) pain. As per the ED provider note, this is a patient who denied medical history and presented with abdominal pain. The patient reported acute onset of left sided abdominal pain when he woke up that morning, which he described as sharp and non-radiating. He had difficulty finding a comfortable position. He denied fever, nausea or vomiting, or shortness of breath (SOB). Exam revealed tenderness in the left upper quadrant (LUQ) and LLQ and left costovertebral angle (CVA) tenderness. Computed tomography (CT) was negative for acute pathology, except for a small left pleural effusion and at least 2 rib fractures on the lateral chest wall. The radiologist subsequently updated this to 4 rib fractures. 

Trauma consult obtained further history where it was noted that the patient reported he went to a concert last night and had a couple of beers. On his way home while waiting for the train, he was leaning against the wall when he started to feel hot and then woke up on the floor. He was able to get up immediately and get to the train. He did not remember the fall. Labs were noted to be unremarkable. Electrocardiogram (EKG) with normal sinus rhythm (NSR). X rays revealed left sided mildly displaced 5-9th rib fracture with associated small pneumothorax and possible pulmonary contusion.

As per Milliman Care Guidelines (MCG) Health General recovery care 27th Edition: Rib fracture ORG: M-545 (ISC) admission is indicated for 1 or more of the following: hemodynamic instability, flail chest, acute respiratory failure (e.g. ["for example], invasive or noninvasive ventilatory support needed or imminent), new hypoxemia, pain (e.g., inhibiting ability to cough or clear airway) that requires inpatient treatment (e.g., not controllable in observation care, outpatient regimen cannot be established), tachypnea that persists despite observation care. This patient did not have a significant rib fracture such as a flail chest, did not have pain which limited his ability to clear her airway, and did not have a significant pneumothorax. He was observed/monitored, all of which should have been done without an acute inpatient admission. Therefore, this patient did not meet guidelines for admission, but rather observation followed by discharge. 

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: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: procedure code 64628 (intraosseous basivertebral nerve ablation)

The insurer denied coverage for procedure code 64628 (intraosseous basivertebral nerve ablation)

The denial is upheld 




This is a patient with a history of chronic pain, including brachial plexopathy and chronic low back pain for several years. The patient's back pain has been unresponsive to lumbar surgery, epidural steroid injections (ESI), opiates, non-steroidal anti-inflammatory drugs (NSAIDs), and neuropathic medication. Records provide no details regarding the lumbar spine surgery. The patient's pain is limiting their activities of daily living (ADLs). The patient's magnetic resonance imaging (MRI) shows evidence of mixed Modic type II/III endplate changes at L (lumbar) 5-S (sacral) 1. The patient's provider treatment with basivertebral nerve (BVN) ablation with the Intracept device. Note that prior lumbar surgery was an exclusion from the Intracept trials.

In assessing whether intraosseous basivertebral nerve ablation using the Intracept device is considered more beneficial for this patient than standard treatments or procedures, it is important to know that the publications in peer-reviewed literature to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation (RFA) for low back pain. 

For individuals who have vertebrogenic low back pain who receive ablation of basivertebral nerves, the evidence includes two randomized controlled trials (RCT) (SMART and INTRACEPT trials, both sponsored by device manufacturer Relievant Medsystems, Inc.). Relevant outcomes were symptoms, functional outcomes, quality of life and treatment-related morbidity. In one RCT, at 12 months, 73% of patients crossed over to the active treatment group and therefore long-term comparative data is not available. Limitations to the other RCT include lack of a sham control and short duration of follow-up. Furthermore, a 2021 systematic review (Conger et al.) concluded that further high-quality, large prospective studies, that are not industry funded, are needed to confirm these findings.

In summary, the supporting publications to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient. 

In summary, the denial of procedure code 64628 (intraosseous basivertebral nerve ablation), date of service to be determined, to be performed at Health Alliance Hospital Broadway campus and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with chest pain. He presented to the emergency department (ED) and was complaining of chest pressure, shortness of breath and fatigue. He felt "clammy" pressure to his mid chest. The severity was mild to moderate. His symptoms started since recent COVID infection. The patient had history of hypertension, on metoprolol and HLD (hyperlipidemia).

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with new onset of chest pain. The patient had coronary risk factors of hypertension. However, the patient was stable, his initial BP (Blood Pressure) was high, but it decreased on oral medications.
The patient had severe lesion of his OM (obtuse marginal) and he underwent intervention of that lesion. However, the patient did not exhibit any of features of acute coronary syndrome: troponin was low, pro - BNP was low, ECG (electrocardiogram) did not reveal any ischemic changes.
The coronary computed tomography angiography revealed anatomic lesion of OM, however, there was no evidence that the lesion was causing chest pain. The lesion had thrombolysis in myocardial infarction (TIMI) 3 flow and was without evidence of an elevated troponin.
Therefore, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain and arm weakness. 
Treatment: Full hospital admission. 
The insurer denied full hospital admission. 
The denial is upheld. 

The patient is an adult female. The patient had a hospital admission for complaints of arm weakness. The patient was experiencing progressive and severe pain after undergoing an anterior cervical diskectomy and fusion of C (cervical) 3-C6 six days earlier. The patient had a history of Parkinson's disease and chronic cervical stenosis. The initial surgery was without complications. The patient developed worsening left upper extremity pain and bilateral shoulder weakness. The patient was treated with a steroid taper and had continued symptoms. The patient presented to the emergency department and had magnetic resonance imaging (MRI) that was reportedly showing spinal cord edema and compression. The patient was transferred to the hospital for special surgery. The patient had magnetic resonance imaging the next day showing slightly improved postoperative stenosis. There was increased signal of the spinal cord at C4-5 with markedly increased central stenosis but improved from the preoperative status. The patient was placed on medications. The patient had left shoulder pain that had mildly improved on day #4, but there was continued numbness and weakness in the left deltoid. Computed tomography (CT) scan showed improvement in the neural foraminal stenosis. The symptoms were consistent with a C5 neurapraxia. The exam on day #4 showed improvement of the left shoulder. Surgical intervention was not recommended. The patient continued treatment with occupational therapy and was discharged to home on day #7. This is a review for the inpatient level of care. 

The inpatient admission was not medically necessary. 

The patient had postoperative pain symptoms after an anterior cervical diskectomy and fusion. The patient had postoperative treatment with a computed tomography scan, magnetic resonance imaging, medications, and therapy. This could have been provided to the patient at a lower level of care basis. The need for the inpatient level of care has not been established based upon the severity of symptoms and the treatment provided to the patient. Thus, the health service with inpatient level of care is not supported.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anemia.
Treatment:  Inpatient Hospital Admission.

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

The patient is an adult female with history of iron deficiency anemia. She was admitted to inpatient level of care for symptomatic anemia (hemoglobin 7.5) with dizziness. Her vitals were stable. The patient was treated with transfusion of 1 unit packed red blood cells (PRBC) and iron infusion. Gastroenterology consultation was obtained, and recommendation was for outpatient esophagogastroduodenoscopy and colonoscopy. On the next day, the patient's hemoglobin was 8.0, and the patient was discharged. The prior denial was for service not being medically necessary. The appeal is for medical necessity.

The requested health service was not medically necessary.

The patient was hemodynamically stable with anemia felt to be due to iron deficiency and menorrhagia, with low suspicion for active bleeding or hemolysis. She did not have syncope, significant cardiac manifestations of anemia, or ischemia symptoms with hemoglobin 7.5 in the emergency department. The patient's hemoglobin improved with transfusion. The patient's care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, Diabetes, Fibromyalgia, Lumbar discopathy, Gastroesophageal reflux disease (GERD)

Treatment: Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week

The insurer denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week

The denial is upheld 


The is an adult female who currently resides in a nursing center. Her diagnoses include Hypertension, Diabetes, Fibromyalgia, Lumbar discopathy, Gastroesophageal reflux disease (GERD), Morbid obesity, Peripheral vascular disease (PVD), Anxiety disorder, Arthritis, Gait instability, Constipation, Cholecystitis, Bipolar disorder, Cerebral vascular accident (CVA), Anemia, Gastro-intestinal (GI) hemorrhage and Allergic rhinitis. 

Mid 2023, uniform assessment (UAS) was performed. The tasking tool noted the need for 39.67 hours assistance per week. The tool noted the need for bathing, shopping, meal preparation, ordinary housework, managing medications, personal hygiene/grooming, dressing, ambulation, toileting, transfers, eating assistance, and laundry care. The member is alert and oriented to person, place and time, and at times experiences episodes of forgetfulness. She is frequently incontinent for bladder and infrequently incontinent for bowel. She does wear pull ups. 

The tasking tool 2 months later, noted the need for 40.83 hours assistance per week. The tool noted the need for bathing, shopping, meal preparation, ordinary housework, managing medications, personal hygiene/grooming, dressing, ambulation, toileting, transfers, eating assistance, and laundry care. The only increase was in the need for eating assistance. 

The review of the tasking tools and uniform assessments (UAS) found that the patient was given adequate time 7 days a week to care for her needs. There was no indication the patient would need additional hours to support her needs. The 42 hours she currently receives is assessed as enough to provide her assistance with her activities of daily living (ADLs). 

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 Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Class I malocclusion; impacted teeth.
Treatment:  D8070 Braces, D8670 Monthly Visit x4.

The insurer denied: D8070 Braces, D8670 Monthly Visit x4.  The denial is overturned.

The patient is an adolescent female. The request is for orthodontic benefits with monthly visits. The patient has a Class I malocclusion. The prior denial was due to a score of 12 points on the handicapping index scale.

The requested health service is medically necessary.

The patient has 3 permanent anterior teeth (#'s [numbers] 6,11 and 27) that are impacted where extraction is not indicated. These are 3 automatic qualifiers for orthodontic benefits according to the handicapping index scale. Orthodontic treatment is needed to correct these issues and the monthly visits are needed to make sure treatment progresses properly. This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness, Poor balance
Treatment: 65 hours per week, consumer directed personal assistance services, level 2
The insurer denied 65 hours per week, consumer directed personal assistance services, level 2.
The determination is overturned.

The patient is a male with a medical history notable for dizziness, weakness, and poor balance. The patient is approved for 45 hours per week of consumer directed personal assistance services. The patient and his care team requested an increase to 65 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has been falling more frequently over the last few months. The most recent fall occurred while he was ambulating to the bathroom. He has had resulting neck pain in addition to his chronic low back pain. This has led to difficulty in ambulating prolonged distances, showering, dressing, toileting, and transfers. Due to these difficulties, the physician requests an increase in personal care hours.
A Uniform Assessment System (UAS) was completed. The assessment was conducted via teleconference. The patient lives with his spouse, who is not able to help with personal care due to her own conditions. The patient was alert and oriented with periods of forgetfulness. His recall was 1/3 at 5 minutes. He is able to direct his own care and call for help in an emergency. For his Instrumental activities of daily living (IADLs), the patient requires extensive or maximal assistance for all. For his activities of daily living (ADLs), the patient requires extensive assistance for bathing, hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. He ambulates with a walker and needs assistance for transfers. He is occasionally incontinent of urine and is continent of stool; he uses pull ups for incontinence care. There were two or more falls in the previous 30 days. No pressure ulcer was present. Compared to an assessment from the prior year, the patient demonstrated similar cognitive and functional status. At issue is the medical necessity of 65 hours per week, consumer directed personal assistance services, level 2.

The requested health of 65 hours per week, consumer directed personal assistance services, level 2 service is medically necessary for this patient.
The patient requires personal care assistance with almost all activities of daily living, including toileting, transfers, and ambulating. He has had multiple recent falls while attempting to perform ADLs independently, which is evidence of unmet personal care needs. The task tool recommended hours can provide a starting guideline for a patient, but if they have personal care needs which are not met at that allotment of hours than a reasonable increase is clinically indicated. His UAS did not demonstrate a decline in functioning, but his physician reports that he has declined and requires additional help as well. The request is therefore medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic adenocarcinoma
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 6.5 hours/day, 7 days/week, for a total of 45.5 hours/week
The insurer denied CDPAP: 6.5 hours/day, 7 days/week, for a total of 45.5 hours/week. 
The determination is overturned.

This is a female patient with a medical history notable for metastatic adenocarcinoma and history of cerebrovascular accident. The patient is approved for 4.5 hours/day, 7 days/week, for a total of 31.5 hours/week of consumer directed personal care assistance. The patient and her care team requested an increase to 6.5 hours/day, 7 days/week, for a total of 45.5 hours/week. This request was denied by the health plan.

The patient provided a letter of support on her own behalf. The letter states that several years ago she had a stroke that impaired her memory and mobility. She was diagnosed with stage 4 metastatic adenocarcinoma from the ovaries. Over the last several months, she has undergone three surgeries and chemotherapy. She states that this has significantly impacted her mobility and even simple activities like walking are extraordinarily difficult for her. She struggles with things like holding a glass of water and taking medication.

The patient's gynecologic oncologist provided a letter of support for this appeal. The letter states that the patient has chronic pain, weakness, poor balance, and unsteady gait as a result of her condition. She, therefore, struggles with meal preparation, walking, bathing, shopping, and medication administration. The provider recommends an increase in home health care hours.

A Uniform Assessment System (UAS) was completed. For her activities of daily living (ADLs), the patient required maximal assistance for bathing, dressing lower body, and toilet use. She required extensive assistance for essentially all others. She is continent of urine and infrequently incontinent of stool. A task tool associated with the assessment recommended 5.5 hours/day to address the patient's personal care needs. Compared to a prior assessment, the patient showed a slight decline in functional status. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP): 6.5 hours/day, 7 days/week, for a total of 45.5 hours/week.

The requested health service of CDPAP: 6.5 hours/day, 7 days/week, for a total of 45.5 hours/week is medically necessary for this patient.

The patient requires maximal or extensive assistance for all ADLs. This includes bathing, toilet use, and transfers. The task tool recommended 5.5 hours/day as a minimum to address her personal care needs. The requested modest increase to 6.5 hours/day is reasonable in light of her medical conditions. The most recent assessment was conducted on the patient nearly 8 months ago. The documentation states that she has subsequently had multiple surgeries and rounds of chemotherapy which have worsened her overall condition. This is to be expected given the patient's condition and prognosis. The requested increase is medically necessary and reasonable for the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Dry eye syndrome
Treatment: Miebo (perfluorohexyloctane) drops
The insurer denied Miebo (perfluorohexyloctane) drops.
The health plan's determination is overturned. 

The patient is a female with dry eye syndrome for whom coverage of Miebo (perfluorohexyloctane) drops is the subject of review. Coverage was previously denied in the absence of documented failure, contraindication, or intolerance to Restasis (cyclosporine) 0.05% (percent).

A formulary exception is indicated in this case. Based on the records provided, the formulary drug, Restasis, has been associated with adverse effects (burning sensation) and lack of efficacy in this patient.

According to the records provided, it is reported that the patient tried Restasis and complained of both burning sensation and lack of efficacy. Additionally, the patient has tried artificial tears (Refresh Plus, Systane, TheraTears) and Pred Forte. The provider states that Miebo is the only prescription eye drop that directly targets tear evaporation. An exam note documents the patient using TheraTears. Punctal plugs were placed, Restasis was discontinued and Miebo was prescribed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Lower Extremity Cellulitis. 
Treatment: Inpatient stay. 
The insurer denied coverage for the inpatient stay. 
The denial is upheld. 

The patient has a past medical history significant for coronary artery disease, gastroesophageal reflux disease (GERD), and kidney stones who presented to the emergency department with complaints of right lower leg pain and swelling following an insect bite. 

Vitals on presentation included: Temperature (T) 97.9 degrees Fahrenheit (F), Blood Pressure (BP) 145/95, Pulse (P) 77, Respiratory Rate (RR) 18, Oxygen (O2) Saturation 97% on Room Air (RA). Laboratory results included the following: White Blood Cell (WBC) Count 4.7, Hemoglobin (HGB) 17.8, Hematocrit (HCT) 52.6, creatinine 0.9, glucose 107, Erythrocyte Sedimentation Rate (ESR) 28, and C-Reactive Protein (CRP) 51.8. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for right lower extremity cellulitis. Duplex ultrasound was negative for deep vein thrombosis (DVT). Infectious Diseases consulted and adjusted antibiotics. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Levaquin and minocycline) as an outpatient. 
 
According to documentation, the patient presented with right lower leg cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on the above findings, the 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 the full hospital admission is not substantiated.