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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All). 

The insurer denied Intracept Procedure. 
The denial is upheld in whole. 

This patient is a female who has a history of low back pain and lumbar radiculitis. She had lumbar epidural injections with 2 weeks of pain relief. She was recommended for another lumbar epidural steroid injection. Her pain was level 8-10/10. She had other treatments including physical therapy (PT) and pain medications without success. Her physical examination (PE) revealed tenderness to palpation in left paraspinal region, and a positive facet loading test. The magnetic resonance imaging (MRI) scan showed a left foraminal disc herniation abutting left lumbar (L)3 nerve root, and moderate to severe facet joint arthropathy at L4-5 level, type II Modic changes at L5-sacral (S)1 level.
At issue is whether the proposed health service or treatment Intracept procedure is likely to be more beneficial than any standard treatment or treatments for this patient.

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

The proposed health service or treatment Intracept procedure is unlikely to be more beneficial than any standard treatments for the patient's medical condition.
The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. The available medical records did not show adequate evidence to confirm this patient's pain was from vertebral bodies. This patient was diagnosed with lumbar radiculitis, and she responded to a prior epidural injection, which indicated lumbar radiculitis as a significant pain generator. PE was remarkable for positive facet load test, which suggested facet arthritis might contribute to her symptomatology. The MRI revealed L3-4-disc herniation with possible impingement of left L3 nerve root and moderate to severe L4-5 facet joint arthropathy. Truumees' study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.  Given this patient's medical history, PE, MRI reading, and the current clinical evidence, she is not an appropriate candidate for the Intracept procedure.
Therefore, the proposed health service or treatment Intracept procedure is unlikely to be more beneficial than any standard treatments for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All). 

The insurer denied Intracept Procedure. 
The denial is upheld in whole. 

This patient is a female with a diagnosis of lumbar radiculopathy. A magnetic resonance imaging (MRI) scan of the lumbar spine demonstrated lumbar (L)3-4-disc protrusion, L3-4 ligamentum flavum hypertrophy. The patient has undergone a prior lumbar epidural steroid injection. The physical exam demonstrated mildly antalgic gait, left paraspinal musculature tender to palpation, and facet loading positive extension. There was a recommendation for the Intracept Procedure by her provider.
At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

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

The proposed health service or treatment Intracept Procedure 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 an Intracept Procedure or intraosseous basivertebral nerve ablation. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A United States 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 a lack of data to recommend this procedure as a treatment modality. In general, there is a lack of substantial support for this procedure, and it is currently not considered the standard of care.
Given this, the proposed health service or treatment Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia

Treatment: D6010 implant placement for tooth: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31

The insurer denied coverage for D6010 implant placement for tooth: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits an edentulous maxilla and oligodontia in the mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further, the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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

Based on the above, the medical necessity for the D6010 implant placement for tooth: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia

Treatment: D6010, implant placement for tooth 2, 3, 4, 5, 14, 15, 18, 19, 29, 30, 31 and D7951 sinus augmentation

The insurer denied coverage for D6010, implant placement for tooth 2, 3, 4, 5, 14, 15, 18, 19, 29, 30, 31 and D7951 sinus augmentation

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants and sinus augmentation. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph; the patient exhibits oligodontia in the maxilla and mandible. In regard to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

An appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment, this renders the endosteal implants and associated services not medically necessary.

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

D6010 implant placement on teeth:  #2, #3, #4, #5, #14, #15, #18, #19, #29, #30 and #31 and D7951 sinus augmentation is not considered medically necessary for this patient.
The insurer's denial of coverage for D6010, implant placement for tooth 2, 3, 4, 5, 14, 15, 18, 19, 29, 30, 31 and D7951 sinus augmentation is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Macromastia.
Treatment: Procedure code 19318, removal of tissue from the breast.
The insurer denied coverage for procedure code 19318, removal of tissue from the breast.
The denial is overturned.

The patient has the classic symptoms for macromastia, and a variety of medical treatments have not improved her symptoms. Her sports medicine physician recommends breast reduction surgery. Her surgeon plans a reduction of at least 1000 grams of tissue total.

Breast reduction surgery is medically necessary for this patient. Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. 

A study by Scholtz et al confirms the paucity of benefits from conservative therapy.  According to the authors, "Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysesthesia. Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation. Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favored by insurance companies. Conservative treatments do not eliminate the causes of the illness."  

The patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Photos show that she has oversized breasts. Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and hundreds of peer-reviewed studies confirm the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. 

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 procedure code 19318, removal of tissue from the breast is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal; vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the hospital ED (emergency department) with upper abdominal pain and vomiting that was progressive over 2-3 weeks. He had been previously evaluated with an abdominal CT (computed tomography) scan that showed gallstones.

At the time of presentation, the patient was without fever and vital signs showed a heart rate of 56/minute and blood pressure of 134/82 mmHg (millimeters of mercury). He was tender in the upper abdomen. The WBC (white blood cell) count was elevated at 12.8 K (thousand). The complete metabolic panel identified normal AST (aspartate aminotransferase) and slightly elevated ALT (alanine aminotransferase). Bilirubin was 1.8. CT (computed tomography) scan showed cholelithiasis (two large stones).

The patient was initially treated with IV (intravenous) fluid and antiemetics. Surgical consultation was obtained and laparoscopic cholecystectomy with a cholangiogram was performed. Surgery was completed without complication.

The patient tolerated oral intake. He was discharged from the inpatient setting with instructions for outpatient surgical follow up.

The health plan rationale for denial per the letter is that the patient was clinically stable and had gallbladder surgery. He experienced no complications of surgery and the treatment provided could have been rendered in the ED (emergency department) and it was not medically necessary to stay in the hospital beyond evaluation, treatment and a period of monitoring (per this letter).

No, the Inpatient admission was not medically necessary.
This patient is a man who presented to the ED (emergency department) with abdominal pain. Evaluation identified gallstones. He was hemodynamically stable at the time of presentation. The WBC (white blood cell) count was elevated at 12 K (thousand), and serum chemistries showed slight elevation of bilirubin and AST (aspartate aminotransferase). The patient had no significant comorbid health conditions that required an inpatient designation. Laparoscopic cholecystectomy was performed without complication. The patient remained hemodynamically stable during the period of monitoring. A lower level of care would have allowed for overnight monitoring, surgery, confirmation of clinical stability, and diet advancement.

A lower level of care would have been appropriate. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care in this case.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia.

Treatment inpatient hospital stay.

The insurer denied coverage for inpatient hospital stay.

The denial is overturned.

The patient has a history of hypertension (HTN), hyperlipidemia (HLD), and obesity. The patient presented to the emergency department (ED) after being sent by his pulmonologist for pneumonia. The patient reported fever and cough for about 1 week. He had been seen at urgent care the previous week for same. He was tested for Coronavirus and was negative. There were no imaging studies done. The patient's symptoms did not improve. The patient continued to have fever so went to the Hospital. Computed tomography scan was done there and revealed left lower lobe (LLL) pneumonia. The patient was sent home on oral (PO) Augmentin. The patient continued to have fevers, headache (HA), weakness, dyspnea on exertion (DOE), gastrointestinal (GI) symptoms and diarrhea. The patient reported temperatures (T) to 101.5 Fahrenheit(F). The patient went to his primary care physician who referred him to the hospital.  Vital signs in the emergency department (ED) T 99.5 F, heart rate (HR) 73, respiratory rate (RR) 20, Blood pressure (BP) 145/69 and oxygen saturation (O2 sats) 93%. The patient was noted to have crackles on exam over LLL.  White blood count (WBC) was 9.4 with a left shift and increased bands. The patient had imaging studies which revealed a multi lobar pneumonia (PNA) - Lingula and LLL.

The patient was admitted to the hospital for treatment with intravenous antibiotics - Rocephin and Azithromycin started. The patient continued to be febrile after admission.

The patient was also noted to have elevated liver function test (LFT) with transaminitis and elevated alkaline phosphatase. A right upper quadrant (RUQ) sonogram was done which revealed hepatic steatosis. The patient was seen by infectious diseases (ID) who recommended to switch antibiotics to Zosyn and Doxycycline. The patient continued to be febrile. Temperature Max was 101. Procalcitonin was elevated at 0.29

This patient had a multi lobar PNA had failed outpatient management with oral antibiotics and had a left shift and bandemia. Oxygen saturations were borderline at 93% on room air. He continued to be symptomatic with fevers for over 48 hours after admission. The patient also developed transaminitis and elevated alkaline phosphatase. Antibiotics were adjusted by the ID team. This patient had already failed outpatient management, had multilobar pneumonia and was showing signs of other system involvement (Liver) hence it was appropriate to admit this patient for close observation, monitoring and treatment.

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

Based on the above, the medical necessity for the inpatient hospital stay is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure (7 days post-partum).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She presented to the hospital a week postpartum with a
history of shortness of breath, calf pain, chest pain, chills, and cough for three days.
On the patient's exam, pitting edema was noted. Blood pressure was 151/69 to
160/88 and tachypnea of 30 breaths/minute. CT (computed tomography) angio and
trans thoracic echo were performed revealing no evidence of pulmonary embolus,
pleural effusions, and ejection fraction of 50% and some degree of diastolic
dysfunction. She was admitted to the hospital for further workup and was treated for
severe preeclampsia with MgSO4 (Magnesium Sulfate) and given Lasix and
antibiotics. There was a concern for postpartum cardiomyopathy due to the
decreased ejection fraction, effusions, and diastolic dysfunction. Cardiology was
consulted after admission and concurred with the picture of fluid
overload/pulmonary edema and to continue diuresis. Her condition improved, and
she was discharged with plan for follow-up echocardiogram.

The health plan denied the admission due to failure to meet MCG (Milliman care
guidelines) criteria for heart failure including unstable vital signs, hypoxia,
pulmonary infection, lung congestion, renal insufficiency, or complications of severe
peripheral edema and cites MCG (Milliman care guidelines) heart failure criteria.
The facility contends that the admission was medically necessary due to concerns
for possible peripartum cardiomyopathy, severe preeclampsia, and pulmonary
infectious morbidity that would require more than the observation time framework to
resolve.

Yes, the Inpatient admission was medically necessary.

This patient's clinical picture was complicated, and the diagnosis was not clear, even after pulmonary embolism was ruled out. There was a significant concern for the decreased ejection fraction, which in this postpartum setting, in conjunction with her tachypnea and blood pressure would warrant emergent evaluation by a pregnancy heart team, and clearly these issues are distinct from heart failure outside of the context of pregnancy. In fact, peripartum cardiomyopathy is the leading cause of late postpartum death and this condition warrants very close observation. A second concerning diagnosis is postpartum preeclampsia with severe features, for which this patient met the case definition based on severe range blood pressure and pulmonary edema. The American College of Obstetricians and Gynecologists recommends that patients with preeclampsia with severe features be admitted for magnesium seizure prophylaxis and titration of antihypertensives to prevent seizures, strokes, and multisystem organ failure. Therefore, the admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in that the health plan denied coverage for the inpatient admission, which was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Cuff Cellulitis.
Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.  The denial is upheld.

The patient presented a few days after a hysterectomy with low grade fever, abdominal pain and yellowish discharge. She was diagnosed with vaginal cuff cellulitis. Vaginal cuff cellulitis is an infection of the superficial tissues at the vaginal surgical margin after vaginal hysterectomy. Patients typically present after hospital discharge with moderate, but increasing, lower abdominal pain with purulent yellow vaginal discharge. Physical examination will reveal the vaginal surgical margin to be tender out of proportion to what is expected with hyperemia and edema. The adnexa and parametria are nontender. Treatment is outpatient oral antibiotic therapy with a single broad-spectrum agent with close follow-up to assure treatment efficacy.

Recommended regimens for treatment of vaginal cuff cellulitis include:
i.	amoxicillin/clavulanate 875/125 mg (milligram) PO (oral) bid (twice)
ii.	ciprofloxacin 500 mg po bid with metronidazole 500 mg po bid,
iii.	TMP-SMX DS [Trimethoprim / Sulfamethoxazole] po bid with metronidazole 500 mg po bid 

This patient after ruling out vaginal cuff dehiscence could have been treated with oral antibiotics as an outpatient with close follow up. Admission was not medically necessary.

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

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial is upheld.