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

Diagnosis: Abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This is an adult female whose hospitalization is being reviewed. The facility is seeking to qualify this hospitalization as an inpatient admission. This was denied initially based off of the 2022 InterQual criteria: Acute adult cholecystitis. According to criteria, inpatient admission is recommended if there is ascending cholangitis and according to insurance carrier interpreting the documents, inpatient criteria were not met. The patient presented to the emergency room with 10 out of 10 abdominal pain and nausea. The pain was radiating to the back. The patient had a past medical history of gastric bypass surgery and obesity. The patient was found to be tachycardic, tachypneic, and hypertensive. The patient was found to have a positive Murphy sign as well as abdominal tenderness. The patient had an abdominal ultrasound that showed a dilated common bile duct and distended gallbladder. The patient had an elevated alkaline phosphatase (ALP). There was concern for common bile duct obstruction and thus a magnetic resonance cholangiopancreatogram (MRCP) was obtained. The patient was admitted for intravenous fluids and intravenous pain and emesis control. The magnetic resonance cholangiopancreatogram 
showed a common bile duct of 8.5 millimeters and artifact versus small amount of sludge in the common bile duct and moderate distention of gallbladder. An endoscopic retrograde cholangiopancreatography (ERCP) was recommended as the next step, however, given the patient's prior surgical history it was recommended that she be transferred to a tertiary care center. The patient had continued pain while awaiting transfer the next couple days. An order of intravenous Zosyn was also recommended.

The requested health service was medically necessary.

There was some concern that the patient has cholangitis given tachycardia on presentation. There was some concern that the patient had common bile duct obstruction given the dilated common bile duct and abnormal magnetic resonance cholangiopancreatogram as well as persistent abdominal pain. Given patient's prior surgical history, the patient required transfer to a tertiary care center for an endoscopic retrograde cholangiopancreatography that would definitively diagnose and treat common bile duct obstruction/suspected cholangitis. Given the totality of evidence presented in the submitted documentation, the requested health service is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain Management Services (radiofrequency ablation- 1unit)
The insurer denied: Pain Management Services (radiofrequency 
ablation- 1unit)
The denial is upheld.

The patient is an adult male with low back and lower extremity pain that began 11 years ago. Past treatments include chiropractor care, physical therapy, lumbar fusion followed by 
emergent revision ten years ago, lumbar medical branch block, meloxicam, Motrin, tizanidine, and Tylenol. Pain ranges from 3/10 to 9/10. Magnetic resonance imaging (MRI) of the lumbar spine from 4 months ago shows type I Modic change at L4-5, L5-S1 posterior fusion and laminectomy, multilevel degenerative change and disc bulges, and mild to moderate foraminal stenosis. The request for L4 Intracept procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such, the health plan should not cover the requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain Management Services (radiofrequency ablation- 1unit)
The insurer denied: Pain Management Services (radiofrequency 
ablation- 1unit)
The denial is overturned.

The patient is an adult male. The appeals letter notes that the patient has a history of chronic low back pain due to degenerative disc disease that has resulted in the development of vertebrogenic pain identified by degenerative endplate changes frequently known by the eponym Modic on magnetic resonance imaging. The patient has pain and has failed treatment for over six months. Prior treatments include chiropractic care, pain management, physical therapy, and 
lumbar discectomy.

The health plan should cover the proposed treatment.

Based on the documentation provided, the requested Intracept procedure is recommended in this case. The patient has a history of chronic low back pain. Despite prior conservative treatment, the patient continues to be symptomatic, with Modic type changes on magnetic resonance imaging. The patient has tried and failed prior interventional treatments as well. Given that the patient has tried and failed conservative treatments as well as prior interventional treatments, this would be the next available step, given the patient's diagnosis and magnetic resonance imaging findings. The requested health service or treatment is more beneficial than any standard treatment for the patient's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain Management Services (radiofrequency ablation- 1unit)
The insurer denied: Pain Management Services (radiofrequency 
ablation- 1unit)
The denial is upheld.

The patient is an adult male who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy (PT), chiropractic care, and home exercises. The patient has failed multiple medications, including potent opiate medications. Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not reveal any neurological injury. He has failed previous lumbar spine surgery.

The health plan should not cover the requested health service.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an adult male who has chronic low back pain. An Intracept procedure has 
been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy (PT), chiropractic care, and home exercises. The patient has failed multiple medications, including potent opiate medications. Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not reveal any neurological injury. He has failed previous lumbar spine surgery. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient in this case has not failed or attempted facet joint interventions or sacroiliac joint injections, which are common treatments of axial low back pain. There is documentation that an initial medial branch block (facet joint intervention) has been recommended, but no 
documentation on the results. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternative sacroiliac injections do show favorable outcomes in the literature and have lower risk and 
morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: frequent falls/decreased mobility
Treatment: home health care
The insurer denied Home Care / Personal Care Level 2 Personal Care Services: Increase to 70 Hours per Week 
The health plan's determination is overturned. 

This is a female patient with a history of dementia, hypertension, diabetes mellitus, neuropathy, gait imbalance, frequent falls, osteoarthritis, and urinary incontinence. 

Home Care / Personal Care Level 2 Personal Care Services: Increase to 70 Hours per Week are medically necessary for this patient.
There is documentation in the Uniform Assessment System (UAS) of the patient requiring maximal assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been utilized to calculate hours given that the patient has unscheduled and unpredictable care needs.

There is documentation from the patient's provider of medical necessity of increased Personal Care Services. The patient lives alone and does not have informal support for the entire time outside of the previously assigned Personal Care Service hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in personal care services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a substance abuse disorder who presented to the emergency room (ER) with dental pain. The patient was diagnosed with a submandibular abscess and admitted to the oral and maxillofacial surgery service where he underwent an incision and drainage on the following day. On postoperative day number one, the patient was feeling better and left against medical advice. At issue is the medical necessity of an inpatient admission.

Patients presenting with signs of sepsis, facial swelling, trismus (limited mouth opening), or dysphagia should be reviewed by a dental or maxillofacial surgeon without delay for appropriate surgical and medical management. Prompt assessment and referral to a tertiary hospital are required for cases at risk of airway compromise. Treatment involves draining the abscess, providing antibiotic support, pain control, and removal of infectious tooth source. Often oral antibiotics with timely dentist appointment for dental caries intervention is sufficient. Dental abscesses may not require admission to the hospital and administration of intravenous (IV) antibiotics unless the patient presents with worrisome features that include fever, dyspnea, or airway compromise secondary to swelling. Hospital admission criteria for infection are a threat to airways or other vital structures, need for general anesthesia, septic fever, marked swelling, need for inpatient control of concomitant systemic disease, and need for intravenous antimicrobial treatment. An oromaxillofacial infection can be expected to heal well initially by removing the infection source and performing proper drainage,
This patient needed general anesthesia and intravenous (IV) antibiotics, however, there was no threat to the airway, there were no signs of sepsis as the patient was afebrile and the vital signs were stable. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease, clotted arteriovenous graft
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient is a male with a history of end stage renal disease (ESRD) on hemodialysis who presented to the hospital with a clotted arteriovenous (AV) graft and missed dialysis.  An ultrasound showed a clotted AV graft and he had a temporary dialysis catheter placed after which he was dialyzed three times. Upon returning to the United States, he presented to his outpatient clinic and then was sent to the emergency room. He did not have any complaints. He was admitted for further management. Nephrology and vascular surgery were consulted. He was placed on dialysis via his temporary hemodialysis (HD) catheter which was then removed due to bleeding. Follow up was planned with vascular surgery for thrombectomy of the AV fistula or placement of a new tunneled catheter. He could not be set up for outpatient dialysis as he lost his dialysis chair due to being out of the country. It was determined that he could not be safely discharged until outpatient dialysis was established. The patient did not want to wait until Monday and signed out against medical advice. At issue is the medical necessity of an inpatient hospital stay.

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with a non-functional dialysis catheter and a missed dialysis treatment. He was hypertensive but in no acute distress. He had hyperkalemia without electrocardiogram (EKG) changes. He did not have cardiac arrhythmias or respiratory distress. He did not have uremic encephalopathy, pericarditis, or bleeding. He did not have severe or persistent changes in mental status. His temporary HD line was removed and he needed outpatient follow up for AV graft declot versus placement of new dialysis catheter. He did not have an established outpatient dialysis spot but did not have any urgent need for dialysis therapy. He could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Peripheral Neuropathy

Treatment: Pain management services: spinal cord stimulator trial

The insurer denied coverage for pain management services: spinal cord stimulator trial

The denial is upheld 

This patient has diabetic peripheral neuropathy. The patient has tried physical therapy, a home exercise program, and topical creams.  The patient's medications trials have included Oxycodone, Hydrocodone and Gabapentin.  The patient has had a psychiatric evaluation and clearance for a spinal cord stimulator trial.  The request is for a 10 kilohertz (kHz) Senza Spinal Cord Stimulator (SCS).

Henson et al (1) "performed a systematic literature review to evaluate the safety and effectiveness of this procedure. A literature search identified 14 prospective studies. Based on our analysis of the available evidence, there is moderate-quality evidence for the safety and efficacy of spinal cord stimulation for painful diabetic neuropathy.  However, further high-quality research, including a large-scale randomized controlled trial is warranted."

An important trial (2) supported the use of high frequency spinal cord stimulation.  However, this trial was limited to only 6 months of follow up and at least 2 years of follow-up is suggested:

"Evidence-based treatment guidelines should contemplate positioning of 10-kHz SCS in the continuum of care. Follow-up of this study population will continue for 24 months and establish potential durability of this treatment beyond 6 months."

SCS placement is not medically reasonable and necessary.  There are other evidence-based therapies available to this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for pain management services: spinal cord stimulator trial is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a history of PSVT (Paroxysmal supraventricular tachycardia), thrombocytopenia, urticaria, and scoliosis, who was directly admitted from home according to the recommendation of her cardiologist. The patient was admitted due to a five-day history of fever, myalgias, mild headache, non-productive cough, and weakness. Initial workup during the cardiology appointment revealed a normal white blood cell count, but positive blood cultures for gram-positive cocci and an elevated C-reactive protein (CRP) level of 133. A chest X-ray showed left lower lobe opacities suggestive of pneumonia.

The inpatient hospital admission was not medically necessary for this patient. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. According to the nationally accepted standards of care, admission at the acute inpatient level of care for patients with pneumonia is recommended in cases of hypoxemia, hemodynamic instability, severe or persistent altered mental status, dehydration, bacteremia, moderate risk or high-risk category patients based on the pneumonia severity index class four or five, or for patients who received a score of two on CURB-65 score for pneumonia severity. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The blood cultures represented a contaminant and not real bacteremia.
Therefore, observation was appropriate to administer antibiotics while waiting for the final results of the blood cultures as well as to monitor for signs of clinical improvement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gout
Treatment: Krystexxa (J2507)
The insurer denied: Krystexxa (J2507)
The denial is upheld.

This patient is an adult female with history of chronic gout. The patient had a dual energy CT (computed tomography) scan done that showed tophi within many different areas including hands, wrists, elbows, feet and also showed erosive changes from the gout. The request for Krystexxa was initially denied due to documentation not indicating that the patient has tried and failed other treatment options and there is no documentation that the physician has checked a G6PD (glucose-6-phosphate dehydrogenase) level prior to starting treatment. On exam the patient also has extensive tophi appreciated on her hands, multiple proximal interphalangeal joints as well as in her feet with deformities noted to the joints due to tophi. The reason the provider is appealing the determination is because the provider does not feel that using allopurinol or Uloric would be affective given her extensive urate burden and the patient is going to be receiving a G6PD (glucose-6-phosphate dehydrogenase) level. 

The requested health service is not medically necessary. 

The Food and Drug Administration (FDA) prescribing guidelines is that Krystexxa is for those patients refractory to other therapies for treatment of gout. This patient has not tried and failed other medications at this time such as allopurinol or Uloric and there is no contraindication for these medications. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic 
Surgical Services

Diagnosis: Back pain
Treatment: Spine Surgery (Percutaneous Laminotomy/Laminectomy)
The insurer denied Spine Surgery (Percutaneous Laminotomy/Laminectomy.)
The health plan's determination is upheld. 

The patient is female with low back pain and R>L (right greater than left) posterolateral leg pain. Activities make her pain worse. Pain medication and heat make her pain better. Physical exam was notable for pain with palpation of paraspinals and sacroiliac (SI) joints, pain with lumbar flexion and extension, and positive provocative findings on SI exam. Electromyography (EMG) / nerve conduction study (NCS) demonstrated a R L (lumbar) 4 chronic radiculopathy.

The Spine Surgery (Percutaneous Laminotomy/Laminectomy) is not medically necessary for this patient.
The patient is a female with primarily low back pain. In recent months, she also reports posterolateral leg pain that is worse with activities. Her treatment has been primarily focused on facet arthropathy and sacroiliac (SI) joint pain. She has received excellent benefit from MBB (medial branch block) injections, lumbar radiofrequency ablation (RFA), and SI joint injections. While I agree that the patient has stenosis at L2/3 based on the radiology report, her symptoms and treatment have been focused on her lumbar facet arthropathy and SI joint pain. No clear symptomatic neurogenic claudication due to spinal stenosis is documented. Therefore, the requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left breast ductal carcinoma in situ
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient is a female with left breast ductal carcinoma in situ (DCIS) who underwent a left mastectomy with sentinel lymph node biopsy and immediate aesthetic flap closure. Her procedure was uncomplicated and she was admitted to the hospital at the acute inpatient level of care postoperatively. On postoperative day number (#) 1, she was hemodynamically stable and her pain was controlled with oral pain medications. She was discharged to home in stable condition. At issue is the medical necessity of an inpatient level of care.

There is no indication of an emergency hospital admission in the records provided. The patient was admitted to the hospital at the acute inpatient level of care following an uncomplicated mastectomy, sentinel lymph node biopsy, and aesthetic flat closure. Her operative course was uncomplicated as was her postoperative recovery, and she was discharged to home in stable condition on postoperative day #1. The services provided could have been provided at a lower level of care rather than at the acute inpatient level of care.