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

Diagnosis: Chronic abdominal pain
Treatment: Inpatient hospital services
The insurer denied coverage for the inpatient hospital services.
The denial is upheld.

The patient had a history of a sleeve gastrectomy, hiatal hernia repair, video assisted thoracoscopy (VATS)/thoracotomy, and anemia and presented with epigastric pain. She was afebrile but had a mild tachycardia. There was no abdominal rebound or guarding. There was no leukocytosis. The hemoglobin was 9.7. She was noted to have chronic epigastric pains and was given narcotics. A Pain Management consult was obtained. A previous workup included having an endoscopy which revealed a 3-centimeter hiatus hernia with reflux esophagitis and a Bravo potential of hydrogen (pH) capsule was placed. A computed tomography (CT) scan done was negative for the cause of the pain. The gastroenterologist advised that an endoscopy could be repeated as an outpatient. 

Milliman Care Guidelines (MCG) clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient was having chronic abdominal pains. She required further workup and pain control, but this could have been done on an outpatient basis. She did not require any acute interventions. She had chronic anemia but was not actively bleeding. She did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. She remained stable for outpatient care. 

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 inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a male with past medical history of deep vein thrombosis (DVT), pulmonary embolism (PE) status post inferior vena cava (IVC) and superior vena cava (SVC) filter placement, on Fondaparinux therapy, hypertension, cardiac loop recorder implantation secondary to syncope, and asthma, who presented to the hospital emergency room, from the podiatry clinic for left foot pain. An urgent consult was placed for podiatric evaluation, with concerns of osteomyelitis, and it was recommended that the patient be admitted for intravenous (IV) antibiotics. The patient was started on IV clindamycin, aztreonam and vancomycin. Magnetic resonance imaging (MRI) was ordered for further evaluation. Per the records made available, the patient had recently been discharged from a nearby hospital for the same foot pain and the concern of osteomyelitis was low. He was also scheduled for outpatient IV antibiotic therapy. Furthermore, there was hyperpigmented skin over the left foot and lower leg with superficial linear ulcers. Tenderness to palpation over the left great toe, dorsum of foot, the heel, post aspect of lower third of leg. No swelling, abscess. Per the records the patient was noncompliant and had a drug seeking history. On admission the records state a 9/10 pain level. Vitals on admission were normal; however, on hospital day #2 and #3 the blood pressure was elevated. X-rays were negative for osteomyelitis. Erythrocyte sedimentation rate (ESR) was elevated, and white blood cell (WBC) count was significantly decreased. The patient left the hospital against medical advice. The records show that a psychiatric consult was performed, and the patient was deemed capable of making an informed decision.  

The patient had clearly been to multiple hospitals with complaints of pain and outpatient antibiotic therapy had not helped. As such it was appropriate to admit the patient for IV antibiotics and further imaging. "MRI is the best imaging modality for establishing the diagnosis of osteomyelitis as it can demonstrate bone marrow oedema, confirm the presence of abscesses and delineate extraosseous disease spread." (1) In addition, studies have shown that there are significant readmission rates in patients on outpatient parenteral antibiotic therapy. (2)  

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 the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld.

The patient is a female with history of cholelithiasis who presented to the emergency room (ER) with complaints of right upper quadrant (RUQ) pain for 3 days. On presentation, the patient had normal vital signs. Complete blood count (CBC) and liver function tests were normal. Ultrasound (US) revealed cholelithiasis without cholecystitis. The patient underwent laparoscopic cholecystectomy and was discharged home after the procedure. The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld in whole. 

The inpatient admission was not medically necessary for this patient. The patient presented with symptomatic cholelithiasis without evidence of acute cholecystitis with normal labs, vitals and diagnostic ultrasound. The patient underwent laparoscopic cholecystectomy which was uncomplicated, and she was discharged home. Acute inpatient admission was not supported by the medical records for cholelithiasis without acute cholecystitis. The patient's care could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Class II Malocclusion and Crowding.
Treatment:  Braces and monthly visits.

The insurer denied braces and monthly visits.  The denial is overturned.

The patient is a male with impacted teeth #6 and #27. Both teeth are completely blocked out and will be unable to erupt without orthodontic intervention. He presents with a skeletal Class II malocclusion and significant crowding. He is treatment planned for braces with premolar extractions to address the crowding and impacted teeth. The subject under review is the medical necessity for braces and monthly visits.

The health plan's determination is overturned.

The treatment of braces and monthly visits is medically necessary for this patient. Patients need to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered. (1) If left untreated the damage that will likely occur to the patient's teeth will be more time consuming and complicated to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. (2) For this reason treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea and Vomiting
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a past medical history (PMH) of gastritis, bipolar disorder (d/o), schizophrenia, and marijuana use who was admitted with complaints of (c/o) a four-day history of nausea/vomiting associated with subjective fevers and chills, similar to prior episodes, no urinary symptoms. Her vital signs were unremarkable. The physical exam was notable for diffuse abdominal tenderness to palpation (TTP) but soft without rebound or guarding. Lab work was notable for bacteriuria. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with cannabis-induced hyperemesis and schizoaffective disorder (d/o) and treated with Zyprexa, Haldol, and Zofran. Psychiatry evaluated the patient and determined that the patient required inpatient psychiatric treatment. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented with intractable nausea and vomiting not responsive in the emergency department (ED) to Haldol or Zofran. Additionally, while the patient was admitted she demonstrated agitated and disruptive behavior, consistent with her diagnosis of schizoaffective disorder. Psychiatry evaluated the patient and did not psychiatrically clear the patient, clearly stating that the patient required inpatient psychiatric level of care for her presentation, as well as medication additions. Overall, this patient required a level of care that could not be safely or appropriately provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure (Thermal Destruction of the Intraosseous Basivertebral Nerve)
The insurer denied the Intracept Procedure.
The health plan's determination is upheld. 

The patient is a female with a history of low back pain. She has had multiple treatments including home exercises, medication management, physical therapy, as well as transforaminal epidural injections. Medications include cyclobenzaprine, Percocet, and Xanax. Nothing has provided significant substantial relief. The pain is rated 10 out of 10. A magnetic resonance imaging (MRI) reported Modic type II changes at L (lumbar) 3-4 and L4-5. There is a request for the Intracept procedure.

The proposed Intracept Procedure (Thermal Destruction of the Intraosseous Basivertebral Nerve) 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. 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure (Thermal Destruction of the Intraosseous Basivertebral Nerve)
The insurer denied the Intracept Procedure.
The health plan's determination is upheld. 

This is a female with a medical history of left hip replacement. It was documented in the medical records that she has a chief complaint of low back pain. She had a lumbar transforaminal epidural injection with 50% (percent) pain reduction of her lower back and radicular symptoms. The physical exam (PE) documented antalgic gait with great trochanter tenderness and positive facet loading test. A magnetic resonance imaging (MRI) revealed multilevel spondylosis and facet arthrosis, Modic changes L (lumbar) 3-4 and L4-5 levels, L3-4 disc bulge with mild bilateral neural foraminal narrowing, L4-5 disc bulge results in contract of right greater than left L4 nerve roots. This patient was recommended to have radiofrequency ablation of basivertebral nerves (Intracept procedure) from L3 to S (sacral) 1.

The proposed Intracept procedure is not likely to be more beneficial than standard for the insured's medical condition.

The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. However, the available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. This patient responded to a prior L4 transforaminal epidural steroid injection and her PE revealed positive facet loading tests. Her MRI revealed multilevel spondylosis and facet arthrosis and disc bulge at L4-5 resulting in contact of L4 nerve roots. These clinical facts are not consistent with vertebrogenic pain. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with clinical evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. Therefore, this patient is not an appropriate candidate for the Intracept procedure based on current clinical studies and her clinical presentation.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure (Thermal Destruction of the Intraosseous Basivertebral Nerve)
The insurer denied the Intracept Procedure.
The health plan's determination is upheld. 

The patient is a female with chronic lower back pain (LBP) for almost 20 years due to an injury resulting in herniation of disc at L (lumbar) 3/4, L5/S (sacral) 1. Her referring physician notes physical and magnetic resonance imaging (MRI) findings are consistent with (c/w) chronic degenerative changes likely exacerbated or caused by her original injury. He notes at least 2 years of chronic LBP causing significant impacts on her activities of daily living (ADLs), including standing for 15 minutes or sitting for 30 minutes. This has resulted in the patient resigning from a cashier job and as a secretary, and she is currently unemployed as a result of her pain. 

Intracept Procedure (Thermal Destruction of the Intraosseous Basivertebral Nerve) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

With respect to this case, the patient has limitations due to her chronic LBP and she is taking Opioids and muscle relaxants to manage the pain. Due to her significant response to ESI (epidural spinal injections) and findings consistent with facet arthropathy, additional therapies targeting the facets and/or repeated RFA (radiofrequency ablation)  may provide significant relief and should be further evaluated despite her long history of multiple therapies. The requesting physician notes that the pts pain is significant and limits ADLs but there is no ODI (Oswestry Disability Index) score. Additionally, the MRI report notes Modic changes and STIR (short tau inversion recovery) imaging was performed but the report does not include comment on its findings. It is hard therefore to determine with the information presented if this patient meets the criteria demonstrated in studies that predict she will benefit from the procedure. Due to the lack of substantiating evidence, the requested procedure is not likely to be more beneficial for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post right total knee arthroplasty.
Treatment: Inpatient level of care.
The health plan denied the requested inpatient level of care as not medically necessary.
The health plan's determination is upheld.

This case describes a male patient with a known history of advanced right knee osteoarthritis. He attempted and failed conservative management of this condition and opted to undergo elective right total knee replacement surgery. The surgery was successful with no documented complications. The patient was admitted to the hospital for inpatient care after surgery. He progressed well with post-operative physical therapy and was deemed stable for discharge.

At issue in this is the medical necessity of the inpatient hospital stay. I uphold, in whole, the health plan's determination of medical necessity in this case. The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient.

This determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature. The provided records document that this male patient underwent elective right total knee replacement. The surgery was successful with no documented complications. The patient had normal lab values and vital signs following the operation. There was no documentation of post-operative bleeding complications or infection. The physical therapy notes document that this patient ambulated 45 feet with a wheeling walker. Thus, based upon the provided documentation in the medical records, the medical necessity of an inpatient hospital stay was not established in this case.

In addition, the current, peer-reviewed orthopedic literature has supported the performance of elective total knee replacement surgery with patients experiencing either short stay or outpatient ambulatory status. Kirkland and colleagues studies readmission rates after joint replacement surgery and found that "Increased length of stay was associated with increased readmission risk. Patients with greater medical comorbidities stay longer to protect against readmission. Optimal length of stay after total joint arthroplasty (TJA) is highly influenced by the patient's overall health. Despite a 300% increase in TJA daily cost, readmission rate has changed minimally over the last 15 years." A second study published by Sutton and his fellow authors in the Journal of Bone and Joint Surgery in 2016 conclude that "Early discharge was not an independent risk factor for 30-day major complications or readmissions following total hip arthroplasty (THA) or total knee arthroplasty (TKA). Rather, increased major complications and readmissions were attributed to patient comorbidities and perioperative variables. Early discharge within the first 2 days postoperatively for risk-stratified patients appears feasible without compromising patient care." Therefore, based upon the provided medical records and the recommendations of the current, peer-reviewed literature, the inpatient hospital admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a female with medical history of uterine fibroid. She presented to the emergency department with right lower quadrant abdominal pain and nausea starting that day. Vital signs were unremarkable. Physical examination was notable for soft, non-distended abdomen with mild right lower quadrant tenderness. 

The inpatient hospital admission was not medically necessary, and the care provided could have been provided at a lower level of care. In patients with uncomplicated appendicitis (without complications such as abscess), such as this one, and without signs of peritonitis, a lower level of care is appropriate. The safety and efficacy of outpatient management of acute uncomplicated appendicitis has been demonstrated. In this case of appendicitis without peritonitis, abscess, fistula, sepsis, or other complication, and subsequent recovery without postoperative complications, such as postoperative infection, pneumonia, or ileus, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right ankle pain
Treatment: Continued Physical Therapy
The insurer denied: Continued Physical Therapy
The denial is upheld

The patient is an adult female who is referred to physical therapy for right ankle pain. Therapy started 6 months ago. A review states that the submitted documentation does not support continued skilled physical therapy services. Coverage was denied as not medically necessary.

The patient was originally seen by her physician and was referred to therapy. She was re-evaluated at one month and continued therapy was recommended by her physician. At 6 weeks the patient continues to have hypersensitivity of the foot. Her functioning is improving; she is able to walk with decreased pain for longer distances. Transfers, standing, squatting, stairs and ambulation remains challenging. The policy was provided for review. Physical therapy notes for the dates of service in question were provided for review.

The proposed treatments are not medically necessary.

The records do not demonstrate a skilled level of care was necessary to perform the physical therapy services. There is no documentation of the supervision provided. Based on the records provided, there is no documentation provided as to why these exercises could not be performed in the home setting. There are multiple studies in the literature showing equivalent outcomes with a home exercise program versus supervised physical therapy for many different orthopedic issues.

The procedures are not in accordance with the generally accepted standards of medical practice. The procedures are not clinically appropriate, in terms of its type, frequency, extent, site and duration and considered effective for the patient's injury and pathology.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood in the Stool. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male, status post colonoscopy with sigmoid polypectomy 3 days prior to presentation. He presented with three days of bright red blood per rectum. He was hemodynamically stable, and Hgb (hemoglobin) was 15.3. The next day, Hgb (hemoglobin) was stable at 15.7. He underwent sigmoidoscopy and was found to have an oozing of blood at the polypectomy site, which was treated with two hemostatic clips. Post procedure his diet was advanced, and he was discharged. 

The Inpatient Hospital Admission was not medically necessary. 

As the patient was hemodynamically stable, with a Hgb (hemoglobin) of 15.3, observation status was appropriate. After the completion of the sigmoidoscopy, there was no ongoing bleeding, and his Hgb (hemoglobin) was stable at 15.7, and he was tolerating a diet, and therefore he was medically stable for discharge. Therefore, observation status was appropriate, and acute inpatient hospital stay was not medically necessary.