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

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

The patient is a female who initially presented to the emergency department with concerns for nausea, vomiting, diarrhea, and chills for one day duration. Pertinent history included alcohol abuse disorder. Initial vital signs revealed a temperature of 98.5 degrees Fahrenheit, heart rate (HR) 95, blood pressure (BP) 122/90, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 99% (percent) on room air. Initial examination documented the patient as alert and oriented without peritoneal signs. Initial laboratory testing revealed a white blood cell count (WBC) 6.2, Hemoglobin (HGB) 12.5, platelets (Plt) 158, international normalized ratio (INR) 0.9, aspartate aminotransferase (AST) 183, alanine aminotransferase (ALT) 79, ethanol (EtOH) 28. Ultrasound revealed hepatic steatosis. A computed tomography (CT) abdomen/pelvis revealed diffuse colitis. The patient was placed in the hospital thereafter with an impression of alcohol withdrawal, nausea, vomiting, diarrhea, and transaminitis. 

The inpatient hospital admission was not medically necessary. The patient had a history of alcohol abuse and presented with nausea, vomiting, and diarrhea. Initial evaluation found the patient afebrile, hemodynamically stable, without significant electrolyte abnormalities, with an elevated AST/ALT, and with CT findings suggestive of colitis. Treatment plan included intravenous fluids and empiric antibiotics. Stool studies were positive for Enteropathogenic Escherichia coli and Norovirus. Following one night of observation care, the patient's symptoms had resolved and was deemed medically stable for discharge. No benzodiazepines were prescribed at discharge indicating they were not necessary. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

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

This is an adult male with a history of Crohn's disease and an ileostomy with reversal. The patient presented to the emergency department (ED) with complaints of right flank pain. A computed tomography (CT) scan revealed a 5 mm (millimeter) stone in the lower right ureter with hydronephrosis on the right ureter. The patient was taken to the operating room by Urology for a cystogram, right retrograde pyelogram, right ureteroscopy with laser lithotripsy, and stent placement. The patient tolerated the procedure well with no complications. He was stable for discharge the following day with an outpatient Urology follow up. This patient had a 5 mm distal right ureteral calculus, no urinary tract infection, no hemodynamic instability or acute renal failure, no bilateral obstruction. 

Per MCG (Milliman Care Guidelines) Health (25th):

1) Renal colic & Kidney stones RRG: the patient fails to meet guidelines for admission to inpatient care. 2) Urologic surgery or procedure GRG. The patient meets the GRG discharge parameter within 24 hours post procedure. This procedure is performed in the ambulatory surgery setting.

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: Upheld

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

The patient is a female who presents to the emergency department complaining of 1 day of abdominal pain. The pain is located to her right lower quadrant. No previous episodes in the past were noted. Physical exam showed right lower quadrant tenderness and positive McBurney's sign. Laboratory studies showed a leukocytosis of 16,000 and the remainder of the labs were normal. A computed tomography (CT) scan was consistent with acute appendicitis. The patient underwent a laparoscopic appendectomy without any complications and was discharged home.

The requested Inpatient Hospital Admission was not medically necessary for this patient
The patient is a female who presented with 1 day history of abdominal pain. She was diagnosed with acute appendicitis. She underwent an uncomplicated laparoscopic appendectomy and was discharged the following day. The patient did not require inpatient status. Services could have been rendered at a lower level of care.
In addition, Multiple studies have discussed same day discharge following laparoscopic appendectomy. Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hip pain
Treatment: Revision of Total Hip Replacement
The insurer denied Revision of Total Hip Replacement. The health plan's determination is upheld.

This case describes a female patient who underwent primary right total hip replacement. She developed persistent right hip pain that has persisted. A plain x-ray of the right hip revealed a small subtle pedestal at the tip of the right femoral stem concerning for early loosening of the femoral stem. The provider planned to obtain an magnetic resonance imaging (MRI) of the right hip with metal subtraction to further investigate the possibility of loosening of the femoral component of the right total hip replacement. The provider stated that further options will be considered when the results of the hip MRI were available. There is no documentation of the right hip MRI with metal subtraction to confirm that the femoral stem was, in fact, loose.

The requested outpatient revision of total hip replacement is not medically necessary for this patient. The provided medical records fail to adequately document that this patient's right total hip replacement is aseptically loose. The orthopedic provider in this case obtained a plain radiograph of the right hip which revealed a small, subtle pedestal at the tip of the prosthesis. The plan was to obtain an MRI scan of the right hip with metal subtraction to confirm that the hip stem was loose. There is no documentation of this MRI study in the provided records. In addition, there is no documentation that a septic work up for the right total hip replacement was negative for infection. Therefore, the documentation in the medical records fail to demonstrate that the proposed surgery is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Other/Status Post Knee Replacement
Treatment: Acute Inpatient Hospital/Continued Admission to an Acute Inpatient Rehabilitation Facility
The health plan's denied the continued admission to an acute rehabilitation facility. 
The health plan's determination is overturned.

The patient is a female with history of chronic bilateral knee pain in the setting of severe osteoarthritis refractory to conservative treatment. She underwent bilateral knee replacement surgery. Her post operative course was complicated by significant post operative pain, functional decline, and syncopal episode secondary to vasovagal event perhaps triggered by intravenous (IV) opioid administration. She was transferred to an inpatient rehabilitation facility for intensive acute inpatient rehabilitation, 3 hours per day at least 5 days week. She made considerable progress in function and was discharged home.
At issue is the medical necessity for continued admission in an inpatient rehabilitation facility.

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

Yes. The health care plan's denial of coverage for inpatient rehabilitation services during the dates in question were not in the patient's best interest, since transferring her to another facility with lower level of care or discharging her home would have jeopardized her rehabilitation potential and perhaps would have contributed to harm due to the safety issues associated with premature discharge from the inpatient rehabilitation facility (IRF).

Post operative recovery times for bilateral total knee arthroplasty surgery tend to be variable, as in the case of the current patient. Additionally, patients undergoing bilateral knee arthroplasty tend to have higher complication rates (see Sobh et. al below) While most individuals do well with minimal or no post operative complications, some take longer to fully recover. In this particular case, the patient experienced prolonged post operative pain that was likely multifactorial in nature, but certainly contributed to delaying her recovery and rehabilitation treatment course. During her admission to the IRF, her pain continued to be a barrier to her functional progress. Within a short time, however, her pain did improve, and it was more effectively managed to the point where she was better able to participate in therapy. As a result, she made significant progress to the point where she was able to be safely discharged home. It was the medical opinion of her IRF treating provider, a board-certified physician in physical medicine and rehabilitation, that she was not safe to be discharged home at an earlier date.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Juvenile Idiopathic Arthritis
Treatment: Rasuvo 10MG (milligrams)/0.2ML (milliliters) SC (subcutaneous) SOAJ (solution auto-injector)
The insurer denied:  Rasuvo 10MG (milligrams)/0.2ML (milliliters) SC (subcutaneous) SOAJ (solution auto-injector)

The denial is upheld.

The patient is an adult female with a history of juvenile idiopathic arthritis (JIA) complicated by macrophage activation syndrome and uveitis. For this, she has tried oral methotrexate but has gastrointestinal (GI) side effects, so the request is to switch to brand name subcutaneous methotrexate (SC MTX) Rasuvo. This was denied coverage by the health plan due to lack of trial and failure or inability to administer generic SC MTX (subcutaneous methotrexate). The patient's provider is appealing the denial.

The requested Rasuvo is not medically necessary.

Rasuvo is not medically necessary. While rheumatologists commonly use SC MTX (subcutaneous methotrexate) to treat JIA (juvenile idiopathic arthritis) and associated uveitis [1,2], there is no reason to justify use of Rasuvo over generic SC MTX (subcutaneous methotrexate). They are the same medication with different delivery devices, and there is no documentation in the provided clinic notes that the patient has tried and failed or cannot safely use generic SC MTX (subcutaneous methotrexate). Therefore, the requested Rasuvo is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture, Right Foot

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult with a history of hyperlipidemia. The patient presented to the emergency room (ER) with complaints of a painful right foot fracture. During the admission the patient underwent a right foot second metatarsal open reduction internal fixation (ORIF). The patient was monitored and evaluated by physical therapy (PT) after surgery. The patient was discharged. 
The patient sustained a low energy type injury at approximately 4 days prior to evaluation in emergency department (ED). He was referred from the office with a concern of vascular compromise. Additional information showed presence of callus. It is important to note callus formation requires several weeks. Evaluation in ED reported tenderness to fracture site and no evidence of neuromuscular compromise. Pain levels were adequately managed with oral medications. There was no reason provided why this person required an admission for acute care. 

The surgical procedure was semi elective without complexity. The Podiatrist performed an open reduction internal fixation and noted callus. He applied a plate and screws. The duration of the operation was likely less than an hour. 

The post-surgical course was non complicated. The vital signs were stable. The reported pain level was 1/10 on post operative day (POD) #1. There were no problems with the wound. Pain medications were tolerated.  Physical therapy services were provided. No other medical conditions required management. There were no extenuating circumstances to substantiate necessity of admission and 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 inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a history of asthma, diabetes, cerebrovascular accident, schizophrenia, hypertension, and uterine cancer with a hysterectomy performed. The presenting complaints were chest pain, shortness of breath, and wheezing. She was prescribed albuterol as an outpatient but her symptoms did not improve. The physical exam was notable for no acute distress and bilateral wheezing. Lab results were notable for an unremarkable troponin and pro brain (or B-type) natriuretic peptide (BNP). Radiology was notable for an unremarkable chest x-ray. In the emergency department (ED), she was given intravenous (IV) steroids and nebulizer therapy; continued wheezing and cough were noted after the nebulizers were given. A re-assessment in the ED noted dyspnea after walking short distances and tachypnea. She was admitted to an inpatient level of care where she was treated with prednisone, nebulizer therapies, and Symbicort. Her dyspnea and wheezing improved and she was discharged.
At issue is the medical necessity of an inpatient stay.

Yes, the inpatient stay was medically necessary. The patient presented with significant dyspnea and wheezing to the extent that she was unable to walk short distances. A trial of outpatient albuterol was unsuccessful in alleviating her symptoms. She was evaluated in the emergency department (ED) and felt to have an asthma exacerbation. Initial therapies resulted in minor relief, but she remained with wheezing and dyspnea to the point that she could not ambulate short distances. She was admitted to an inpatient level of care where she improved and was able to be discharged home safely. The patient presented with an asthma exacerbation that had failed outpatient management and was unable to be controlled significantly in the ED. A lower level of care would not have provided the appropriate levels of treatment intensity for her. No further diagnostic work up or testing was necessary for this patient, but further time spent receiving asthma-targeted therapies was necessary for her to discharge home safely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes.
Treatment: Long Tern Custodial Care.

The insurer denied Long Term Custodial Care. The health plan's determination is upheld.

The patient is a male with a past medical history significant for diabetes mellitus uncontrolled, neuropathy, diabetic ulcer of the heel with necrosis of the bone, hypertension, hyperlipidemia, cerebrovascular disease, seizure disorder, bipolar disease, schizoaffective disorder and right foot ulcer.

Long Term Custodial Care is not medically necessary for this patient.

Per the records, the patient needs limited assistance for most activities of daily living (ADL), and is able to transfer out of bed with little assistance into a manual wheelchair and able to self-propel. The current wound care (dry dressing with Betadine) can be managed through visiting nurses services.

According to current the recent progress note, the patient is noted to be unpredictable at times but has no specific behavioral problems. He is not guarded, depressed or suicidal. It was noted that the patient can self-direct his care.

The patient does not need ongoing inpatient custodial care. The patient has not been treated for psychiatric issues, at least according to the medical record with medications. It was noted in the chart that the patient can self direct his care. The patient can transfer, toilet and move by wheelchair independently. There is no reason noted in the chart otherwise why the patient needs to be confined to custodial care for these issues. The patient's care can be provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer
Treatment: Proton Beam Therapy
The insurer denied proton beam therapy.
The determination is overturned.

The patient presented with stage IIb left (L) breast cancer. She was treated with neoadjuvant chemo-immunotherapy followed by surgery. She is now evaluated for adjuvant radiation therapy (RT) using proton beam therapy. This is under review for medical necessity.
 
The requested health service/treatment of outpatient proton therapy (30 visits) is medically necessary for this patient.

Although proton beam therapy for breast cancer is being evaluated under National Cancer Institute (NCI) sponsored trials, in this case the target of radiation is located directly over the heart as the patient underwent a mastectomy. Due to the anatomy, the mean heart dose is 10.9 gray (Gy) from non-proton treatment. On the other hand, the mean heart dose from proton beam is 1.1 Gy.

This is a young patient with curative disease, where it is vital to keep the mean heart dose to less than 5 Gy to avoid cardiac morbidity and mortality. V20 lung [volume of normal lung receiving 20 Gy] is also 39% (percent) with photon-based treatment which is not an acceptable quantec constraint for lung. The V20 lung from proton beam is 21% which is acceptable.

Although proton beam therapy is still being evaluated for breast cancer, it is medically necessary to avoid cardiac side effects in this young patient. The attending provider (AP) has provided a dose volume histogram (DVH) comparison of photon and proton beam showing the superiority of proton over photon.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis
Treatment: Prolia
The insurer denied Prolia.
The determination is upheld.


The patient has osteoporosis. Prolia was denied by the health plan as the member has not tried or has a contraindication to the preferred medication, intravenous (IV) Reclast. Prior treatment included Fosamax (she had severe myalgia and gastroesophageal reflux disease (GERD)). At issue is the medical necessity of Prolia.

There is no medical reason the patient cannot undergo a trial of the formulary drug, IV reclast. A study published in Bone in 2007 looking at giving IV reclast after Fosamax, concluded that 'patients can be switched from oral ALN [Alendronate-Fosamax] to ZOL [zoledronic acid-IV Reclast] 5 milligrams (mg) infusion with maintenance of therapeutic effect for at least 12 months and that patients prefer a once yearly infusion to weekly oral therapy'. Moreover, a study in Clin Rheumatol 2010 found that 'ZOL is generally safe and well tolerated. Five milligrams of ZOL has the potential to improve compliance with osteoporosis therapy and, consequently, to reduce fracture risk in clinical practice.'
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral infarction.
Treatment: Continue Stay in Skilled Nursing Facility, Level II.
The insurer denied: Continue Stay in Skilled Nursing Facility, Level II.
The denial is upheld.

The patient is an adult male. The patient was admitted for cerebral infarction due to unspecific, occlusion or stenosis of the middle cerebral artery, hemiplegia affecting the left, non-dominant side, dysphasia, ulcer of sacral region, hypertension, dyslipidemia, type two diabetes, and ulcerative colitis. The records show that the patient does have limited ability for activities of daily living and mobility. The patient is alert, and oriented to person and time and place. There is no movement in the left upper extremity and left lower extremity.

The request is for continued stay at the skilled nursing facility.

The proposed treatment is not medically necessary.

Based on the records of this complicated medical case, the patient did have stroke, with hemiplegia, left side of the body, diabetes, hypertension, ulcerative, colitis, and pressure ulcer. However, the patient did not require intensive physical therapy, occupational therapy, daily nursing care, or provider visits to treat his conditions (mainly his pressure ulcers). The patient has plateaued, and he does not require skilled nursing facility with daily physical therapy, occupation therapy, or nursing care for complex wound care. The patient can receive those services at an alternative, lower level of care. The care for this patient could be completed at home with home services, home therapy or other lower level of care. Continued skilled nursing facility is not needed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: low back pain

Treatment: on campus-outpatient hospital/surgical care Intracept Procedure

The insurer denied coverage for on campus-outpatient hospital/surgical care Intracept Procedure

The denial is upheld 

According to the medical records, the patient is an adult who suffers from axial low back pain, who has failed 3 months of physical therapy and oral medications. An Intracept procedure is being recommended.

Scientific evidence on this procedure is not conclusive. The procedure shows promise, but long-term studies and outcomes are not yet available.

On campus-outpatient hospital/surgical care Intracept Procedure to treat chronic vertebrogenic pain has final approval from the appropriate regulatory bodies for this diagnosis. It is Food and Drug Administration (FDA)-approved. 

The patient is not considered a good candidate for the requested procedure. There is not enough documentation (ie a current exam, symptoms, x-ray findings, magnetic resonance imaging, etc.) to determine if the patient meets the criteria for this procedure.

The adverse risks are increased over standard treatment/services.

Management to date has been physical therapy only. There is no documentation of injection management. If all management eventually fails and the back pain is indeed axial with modic changes noted by MRI (magnetic resonance imaging) or X-ray, then this procedure would be the next logical step in minimally invasive management.

"Conclusions: Patients treated with RF (radiofrequency) ablation of the BVN (basivertebral nerve ablation) for CLBP (chronic low back pain) exhibited sustained clinical benefits in ODI (Oswestry Disability Index) and VAS (Visual Analogue Scale) and maintained high responder rates at 2 years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of CLBP" (Fischgrund, J. S. et al. 2019).

"Conclusion: Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period" (Becker, S. et al. 2017).

"Conclusions: Minimally invasive RF ablation of the BVN led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related LBP" (Khalil, J. G. et al. 2019).

In summary, the denial of on campus-outpatient hospital/surgical care Intracept Procedure to treat chronic vertebrogenic pain 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 increased over standard treatments.