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

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

The patient has a history of myocardial infarction (MI), coronary artery disease (CAD), percutaneous interventions, congestive heart failure (CHF), hypertension, carotid disease, cerebrovascular accident (CVA), diabetes, and renal insufficiency. He presented to the hospital with two weeks of left sided chest pain. It occurred with exertion only. The troponin was 0.3. Catheterization demonstrated 2 vessel CAD. He was transferred to the receiving facility for a cardiac catheterization. On arrival, his blood pressure (BP) was elevated. Other vital signs were normal. He was not reported to be in distress. The creatinine was 1.08. He underwent successful and uncomplicated intervention of the left main, circumflex, and ramus arteries. The left ventricular ejection fraction (LVEF) was 47%. He remained asymptomatic, stable, and was discharged. The troponin was 0.04. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. This patient was transferred after experiencing chest pain and a non-ST segment elevation myocardial infarction. There was no CHF, respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e. severe bleeding, CVA), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for a recurrent or ongoing acute coronary syndrome such as increasing cardiac biomarkers or an ongoing abnormal electrocardiogram (ECG). The use of an Impella device during the procedure was elective and there were no procedure related complications. The patient remained stable. In the setting of this case, an acute inpatient level hospitalization, compared to a lower level of care, has not been established as standard of care toward improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus type 2 (DM2), hypertension (HTN), and osteoporosis who was admitted with complaints of (c/o) a productive cough and dyspnea, with an increased use of inhalers. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) 95% on room air (RA), and pulse 111. The physical exam was notable for moderate distress and bilateral expiratory wheezing. Lab work was notable for hyperglycemia and a potassium of 5.9. A A chest x-ray (CXR) showed no acute disease. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with a COPD exacerbation and treated with pulmonary inhaled treatments, steroids, oxygen therapy, and close clinical monitoring. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an inpatient level of care. 

This patient, with a PMH of COPD, asthma, DM2, HTN, and osteoporosis presented to the emergency department (ED) with c/o dyspnea associated with a productive cough. There was no requirement for intubation, carbon dioxide (CO2) narcosis with oxygen saturation less than (<) 90%, severe acidosis, concomitant cardiac disease, acute coronary syndrome, new arrhythmia, congestive heart failure exacerbation, pulmonary embolism, pneumonia, lobar collapse, cyanosis, depressed mental status or altered level of consciousness (LOC), impending respiratory failure, or new ischemic electrocardiogram (ECG) changes. The patient's DECAF [Dyspnea, Eosinopenia, Consolidation, Acidemia and Atrial Fibrillation] score is indicative of a low-risk COPD exacerbation. This patient was treated with intravenous (IV) steroids, pulmonary nebulizers, and close clinical monitoring, and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Pregnancy/childbirth
Inpatient hospital

Diagnosis: postpartum hypertension
Treatment: inpatient stay. 
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female, gravida 8 para 6, who presented to the hospital with a complaint of headache and hypertension. Her evaluation showed she was 11 days postpartum from a vaginal delivery, and had blood pressures sustained in the range of 160-170/100 while in triage. She had a severe headache, and a pre-eclampsia lab panel showed elevations in lactate dehydrogenase (LDH) and uric acid. She was admitted to the hospital early where she received magnesium prophylaxis, intravenous (IV) hydralazine, and oral Procardia to protect her from seizure and treat her hypertension. 

The inpatient admission was medically necessary. The level of danger and the intensity of intervention in this case are compelling reasons why this patient required an inpatient care and could not receive care at a lower level. Postpartum pre-eclampsia is a highly dangerous condition that even in the postpartum setting can lead to seizure or cerebrovascular accident. Control of hypertension is essential, and difficult to establish outside the hospital without the benefit of monitoring. This patient required doses of IV medication upon admission. Even the later utilized oral medications must be started and adjusted while the patient is hospitalized because of the hazard of causing hypotension (unlike essential hypertension, the hypertension of pre-eclampsia is often highly labile and therefore offers an unpredictable response to medication). Observation status refers to interventions that could be accomplished in an outpatient or emergency setting. Magnesium sulfate administration, clearly essential in this case, does not fit that criteria. Intravenous magnesium is considered a high-risk medication, and requires intensive monitoring by nursing staff. Clinical evaluations at least every 30 minutes are standard to monitor for toxicity. The Food and Drug Administration (FDA) labeling for the drug magnesium sulfate is specific about intensive monitoring including tracking of urine output. There is no question an inpatient level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left below knee amputation

Treatment: Continued care at a skilled nursing facility

The insurer denied coverage for continued care at a skilled nursing facility

The denial is upheld 

This is a male with chronic medical problems including diabetes, hypertension and peripheral vascular disease. He underwent a left below knee amputation and was subsequently admitted to a SNF (skilled nursing facility) for subacute rehabilitation. He received physical/occupational therapy and was eventually discharged. Under review is the medical necessity for continued care at a skilled nursing facility (SNF). 

The patient was initially appropriate for the SNF subacute rehabilitation level of care (1, 2, 3). He had functional deficits that were potentially amenable to comprehensive rehabilitation. He participated in physical and occupational therapy with demonstrated gradual improvement. According to the occupational therapy progress notes, the patient was at the modified independent to supervision level for activities of daily living tasks that included dressing and toilet transfers/hygiene. According to the physical therapy note, he required only supervision for transfer activities and using a manual wheelchair. In addition, there were no acute medical or complicated nursing issues that required continued stay at the SNF. Ongoing care could have been safely provided at a lower level (e.g., long term care, outpatient therapy or home therapy).

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued care at a skilled nursing facility (SNF) was not medically necessary.

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

The insurer's denial of coverage for continued care at a skilled nursing facility (SNF) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is overturned. 

The patient is a male who fell on an outstretched right arm and dislocated his right shoulder anteriorly. He was diagnosed with an anteriorly displaced right shoulder with arterial compromise and paresthesias. The patient underwent a computed tomography angiography (CTA) which documented the dislocation and complete occlusion of the axillary artery with possible arterial dissection, with reconstitution of the brachial artery. He underwent a closed relocation. Post reduction, Vascular Surgery consultation was requested, and the patient was anti coagulated with systemic intravenous (IV) heparin therapy. A repeat CTA documented the relocation and the presence of the arterial thrombosis of the axillary artery. A duplex ultrasonography documented subclavian/axillary thrombosis, the absence of an arterial dissection and reconstitution of the brachial, radial, and ulnar arteries. Orthopedic surgery consultation was obtained, and the decision was made to maintain the patient on systemic oral anticoagulation with Eliquis and aspirin therapy. 
At issue is the medical necessity of Inpatient Admission.

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

The requested health service/treatment of Inpatient Admission was medically necessary for this patient.
The patient was found to have an axillary artery thrombosis with possible arterial dissection. This resulted in appropriate further testing, observation and anticoagulation which required the inpatient care. The patient's admission for inpatient care was medically necessary and the physicians actions were with sound medical judgement and in the best interest of the patient. The finding of axillary artery thrombosis is a major complication of his condition and warranted further diagnostic evaluations and consultation with Vascular Surgery. These tests and treatments required an additional night in the hospital. The physicians acted appropriately in their evaluation, consultations, and treatment of an anterior shoulder separation with arterial compromise.
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left peritonsillar abscess with reactive left level II adenopathy

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned

This female patient presented with throat pain and received antibiotics in the emergency department and was discharged.  She had severe pain 10/10 and difficulty swallowing. There was noted difficulty in speaking. She had a temperature 100.1oF (Fahrenheit) and pain on palpation of the swelling in the left neck. The computed tomography (CT) was obtained which showed: "Left peritonsillar abscess with reactive left level II adenopathy". She was admitted to the hospital. The attending physician stated: "My estimation and management as determined that this patient has a medical necessity beyond the capabilities of emergency department for possible PTA (Peri-tonsillar abscess) and failed outpatient antibiotics. The patient requires further management."

During her hospital stay, a needle aspiration of left peri-tonsillar abscess was performed with purulent discharge noted. A full Incision and drainage of abscess was performed with 5 milliliters of foul-smelling purulent drainage expressed.
Following the procedure, her throat pain improved, and she was able to swallow with less discomfort and was discharged. 

The peer-reviewed literature notes that peritonsillar abscesses inpatient have an increased risk of morbidity from the peritonsillar abscess.(1)

The Head and Neck disease MCG (Milliman Care Guidelines) states that: "Clinical Indications for Patient Inpatient Care:

1)	Airway blockage or inability to swallowing

2)	Abscess or swelling causing significant swallowing difficulty

3)	Abscesses or swelling causing airway obstruction or partial obstruction head and neck disease condition, symptom, or finding which emergency and observational care have failed."

The health care plan did not act reasonably nor with sound medical judgment nor the best interest of the patient. The peer-reviewed literature and the MCG guidelines recommend inpatient care for individuals who had difficulty swallowing, possible airway involvement, and failed outpatient antibiotic care. 

The inpatient stay was medically necessary for this patient as she had difficulty swallowing, severe pain, possible infringement airway, failure of antibiotic therapy, and was over years of age which is associated with greater morbidity from peritonsillar abscess.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient stay is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar or sacral
The insurer denied: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar or sacral
The denial is: Upheld.

The patient is a female who has chronic low back pain. Physical exam (PE) revealed tenderness to palpation (TTP) in the lumbar paraspinal region with multiple trigger points, and increased pain with flexion and extension. She did not respond to physical therapy (PT) and non-steroidal anti-inflammatory drugs (NSAIDs). A prior radiofrequency ablation (RFA) failed to provide her with any pain relief. According to the clinic note on 12/2/21, magnetic resonance imaging (MRI) showed right lumbar (L)5-sacral (S)1 paracentral disc herniation and mild multilevel facet hypertrophy.
The issue is whether the proposed thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar, or sacral (Intracept procedure) is likely to be more beneficial for this patient than standard treatment based on the available clinical findings and current studies.

The health plan's determination is upheld.

The proposed health service or treatment thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar, or sacral (Intracept) is unlikely to be beneficial for the insured's medical condition. 
The proposed system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. MRI showed right L5-S1 paracentral disc herniation and mild multilevel facet hypertrophy.
Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with radiographic evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. [1]
Given this patient's MRI findings of L5-S1 paracentral disc herniation and mild multilevel facet hypertrophy and the exclusion criteria from current clinical studies, the patient is not an appropriate candidate for Intracept procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar or sacral
The insurer denied: thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar or sacral
The denial is: Upheld.

The patient is a female with low back pain beginning over 6 months ago. Prior treatments have included home exercises, lumbar injections, lumbar spine surgery, as well as physical therapy. The patient has trialed opioids. Magnetic resonance imaging (MRI) performed demonstrated degenerative endplate changes at lumbar (L)5-sacral (S)1. Her pain score is rated 10 out of 10. There is a request for thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar or sacral, which is the subject under review.

The health plan's determination is upheld.

The proposed health service or treatment thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar or sacral 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 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first 2 vertebral bodies, lumbar or sacral 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: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure
 
The insurer denied comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visits. 
The denial is upheld.

The patient is a female with a Class I occlusion with appropriate overbite and overjet. She has maxillary and mandibular spacing. She is treatment planned for orthodontics to correct her malocclusion, but her health plan rejected the claim on the basis that treatment is not medically necessary. The subject under review is the medical necessity for comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visits.

The requested treatment is not medically necessary for this patient. The patient has some minor spacing. Her overbite is appropriate and there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows she does not have a traumatic deep bite. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no indication from the photographs provided there is an anterior crossbite.
There is no medical reason to correct her malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1)This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion.2) If her teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female with a history of asthma, diabetes, transient ischemic attack (TIA), and osteoarthritis (OA). She presented to the hospital for a scheduled right total hip arthroplasty. American Society of Anesthesiologists (ASA) score was III. The patient was admitted for care. She tolerated the surgery well. There were no complications. Antibiotics were given as ordered. The patient was discharged after a period of hemodynamic stability.

The medical records demonstrated a non-complicated operation and post-surgical course. The medical conditions were taken into consideration. The patient was a diabetic with good control. She had previous TIA years prior.

The blood loss was 200cc (cubic centimeters). After her operation, her vital signs were stable. There was no evidence of fever or bleeding. Her wound was satisfactory. There was no evidence of infection. She had made satisfactory progress with PT (physical therapy) on the afternoon of her surgery. She did not require treatment for other underlying medical conditions. The hospitalist reported, "discharged from a medical standpoint". These findings do not support the necessity for inpatient admission. There were no extenuating circumstances to support the acute inpatient level of service.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.