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

Diagnosis: Low back pain 
Treatment: 22899 - Intracept Procedure - intraosseous ablation of the basivertebral nerve, C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar sacrum, C9753 - Destruction of intraosseous basivertebral nerve, each additional cerebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)

The insurer denied 22899 - Intracept Procedure - intraosseous ablation of the basivertebral nerve, C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar sacrum, C9753 - Destruction of intraosseous basivertebral nerve, each additional cerebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure).

The denial is overturned. 

The patient is a female with chronic low back pain has failed treatment with oral medications including Celebrex and oxycodone, facet injections, and medial nerve branch radiofrequency ablations.  Her low back pain has progressed.  Her lumbar spine magnetic resonance (MR) scan shows L3-4 through L5-S1 disc bulges and herniations as well as degenerative changes including Modic type II changes at L4-5 and L5-S1.   Her treating physician has requested intraosseous ablation of the basivertebral nerve.

Yes, the health plan should cover the proposed treatment.

The health plan should cover the proposed treatment which is current standard of care.  There is ample current peer reviewed literature supporting the efficacy of this proposed treatment.  

Yes, the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease. 

This patient has already failed multiple treatments including minimally invasive treatments.

As stated in the article by Khalil, et al, "Minimally invasive RF ablation of the [basivertebral nerve] led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related LBP."  Further, stated in the article by Lorio, et al, "Intraosseous ablation of the [basivertebral nerve] is a relatively new minimally invasive treatment for the relief of [chronic low back pain] that is diagnosed using well-established clinical and MRI findings.  The procedure is supported by level 1 evidence including 2 RCTs demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies."

Thus there is ample literature supporting the efficacy of this proposed treatment which is now considered the standard of care for patients with same or similar medical conditions as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obsessive Compulsive Disorder (OCD).

Treatment: Deep Brain Stimulation surgery (DBS).

The insurer is denied coverage for deep brain stimulation surgery (DBS). 

The denial is overturned.

The patient is a male currently diagnosed with obsessive-compulsive disorder (OCD). The patient was noted to have long-standing, severe, and intractable OCD. The patient had exhausted all reasonable conventional and several experimental medication treatments. The patient planned to participate in DBS research studies.  The provider requested deep brain stimulation surgery (DBS). 

DBS to be an effective treatment in otherwise treatment-resistant obsessive-compulsive
disorder (trOCD). A recent review of the pooled data concluded that a mean reduction in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) of 38.68 % is obtained following DBS treatment (see Vicheva, et al, 2020).

Final approval from the appropriate regulatory bodies is not needed for this diagnosis. The devices used for DBS for OCD is the same as for other indications of DBS. These devices are FDA approved for DBS in general.

The patient is a good candidate since he has exhausted all medical treatments.

With a 38.68% chance of improvement, this is the best available treatment available, and it meets the standard of care for this patient.

Given that the patient has failed multiple medical treatments (standard and experimental), DBS is medically necessary and meets the standard of care.

The carrier's denial of deep brain stimulation surgery (DBS) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is a male patient with a past medical history of diabetes mellitus, hypertension, hyperlipidemia, and gout. The patient presented to the Emergency Department (ED) with complaints of severe chest pain radiating to the left arm and back. It was exacerbated by movement and deep breathing. The patient's initial exams showed pain score of 10/10, elevated blood pressure of 193/74, acute distress and tenderness to palpation overlying the chest wall. The patient's computed tomography angiogram (CTA) of the chest demonstrated cardiomegaly without evidence of pulmonary embolism. The patient's troponin was negative. The patient's electrocardiogram (EKG) showed possible left atrial enlargement, non-specific T-wave abnormality. The patient was admitted for chest pain. 

The patient's condition was ruled out for myocardial infarction. The hospital course of treatment and management included aspirin, atorvastatin, Robaxin, allopurinol, intravenous (IV) vancomycin, IV cefepime, Lovenox injection, Lipitor, and blood sugar monitoring with insulin sliding scale. The patient was seen by a cardiologist. The patient underwent a nuclear stress test which demonstrated a fixed inferolateral wall effect at the basal level concerning for area of infarction and some stress induced ischemia in the infero-apex. After treatment, the patient was stabilized and cleared for discharged to home on day 3 of admission with primary care doctor follow-up.

Based on the review of the medical record and literature, acute inpatient admission was not medically necessary for this patient. The patient presented to the ED with chest pain. The patient's initial evaluation in the ED was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers. Though it was appropriate and indicated for the patient's symptoms to be evaluated and to rule out acute coronary syndrome, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under an observational level of care, allowing for additional diagnostic testing, as was performed in this instance. There were no high-risk or concerning findings on diagnostic testing to necessitate further inpatient evaluation. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting an acute inpatient level of care. 

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke and residual left sided weakness
Treatment: Increase of Personal Care Assistance (PCA) service, eight hours/day, seven days/week, total 56 hours/week
The insurer denied the Increase of Personal Care Assistance (PCA) service, eight hours/day, seven days/week, total 56 hours/week. 
The denial is overturned. 

The patient is a female with a history of stroke and residual left sided weakness. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 56 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of eight hours/day, seven days/week, total 56 hours/week Personal Assistance Services is deemed medically necessary. 

This is a female with a history of stroke and residual left sided weakness. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to progressive weakness secondary her stroke, the beneficiary requires total assistance for completion of all activities of daily living (ADLs). Therefore, the currently approved plan of 43 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 56 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis.

Treatment: Inpatient admission.

The insurer denied the inpatient admission. 

The denial was upheld.

This is a female patient who presented to the Emergency Department (ED) after being seen at a health center for complaints of reoccurring fever, abdominal pain and generalized weakness.  She presented for abnormal liver enzymes and an elevated white blood cell (WBC) count.  Her past medical history included renal stones, pyelonephritis and urinary tract infections. Her presenting vital signs were: blood pressure of 126/93, heart rate of 124, temperature of 99.9F, and a respiratory rate of 20.  Labs showed a WBC count of 11.1.  The patient was admitted to the hospital for evaluation of fever of unknown origin.  Infectious Diseases was consulted.  A urine culture was positive for Escherichia coli.  A CT scan of chest/abdomen revealed changes consistent with pyelonephritis of the right kidney.  An abdominal ultrasound and a CT scan of the head were unremarkable.  The patient was given intravenous (IV) fluids and IV antibiotics.  She improved, remained medically stable and was discharged home on oral antibiotics with outpatient follow-up.  

They note that the antibiotic course could have been completed at a lower level of care.  The appeal on behalf of the hospital is noted and read in detail.  

Per MCG Health (23rd Edition) Urinary tract Infection (UTI) - RRG, the patient fails to meet clinical indications for admission to inpatient care, but the patient does meet some guidelines for Observation Care:

1)	Fever (temperature 99.9F)
2)	Vital sign abnormality (Heart Rate = 124)

There was no evidence of hemodynamic instability, vomiting that is severe and/or persistent, new onset coagulopathy, urinary system findings that require invasive procedure, altered mental status, or persistence or worsening of clinical findings (fever, pain/despite observation care treatment.) 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

Yes, the Inpatient admission was medically necessary. 

The patient is a male who was admitted with a complaint of low back pain.  According to the documentation, he presented with low back pain, saddle anesthesia, decreased rectal tone, and urinary incontinence. His pain was 10/10 requiring IV medication.  He had an MRI 10 days prior, which showed a large central disc herniation. The patient was actually an inpatient and had surgery scheduled but was unhappy with facility and left AMA (against medical advice).  Physical exam is corroborated with diminished rectal tone, saddle anesthesia in the emergency department.  

The admission was medically necessary.  He had neurological deficits, consistent with his findings on MRI. He meets criteria for inpatient admission.  The patient most likely required urgent surgery; however, he became upset at his treatment of being in a curtained/non-private unit, and left AMA.   The patient's decision to leave against medical advice does not remove or negate the medical indications for his initial admission.  The patient was given an option to wait and hopefully be moved to a private room.  The patient was essentially admitted and was awaiting orthopedic consultation.  This is within a reasonable window being consulted. Therefore, based on review of the medical records, the medical indication for admission is valid, and his treatment was reasonable.  Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain, Cannabis Hyperemesis
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld.


This is a female patient with sickle cell disease and active marijuana use. She presented to the Emergency Room (ER) with right-sided body pain and vomiting. The patient's initial vital signs in the ER were: temperature of 98.9, pulse rate of 61, respiratory rate of 20, oxygen saturation of 100, and blood pressure of 128/81.  The patient was alert and oriented and was in no acute distress. The patient's vomiting was felt to have been cannabis hyperemesis syndrome. The patient was ambulating in the ER, did not seem to be in severe pain and was demanding Dilaudid and Benadryl. It was reported that patient was seen in the clinic that morning of ED arrival and was given refills on oral opioids. An electrocardiogram (EKG) was done with results showed normal sinus rhythm with sinus arrhythmia, nonspecific ST abnormality,; it was abnormal  when compared to an earlier dated EKG. The patient's chest x-ray showed clear lung fields. The patient left against medical advice (AMA).

Based on the review of the medical record, inpatient admission was not medically necessary for this patient. The patient's vomiting was most likely due to cannabis hyperemesis syndrome that commonly occurs with the use of marijuana. Though the patient has sickle cell disease, sickle cell crisis and pain, the patient's pain was not consistent with her sickle cell disease. The patient reported severe pain and demanded Dilaudid and Benadryl. However, the patient was observed to be ambulating and not appeared to be in acute distress. Consistent with literature, this patient with sickle cell disease had chronic pain that was treated with opioid analgesics. The patient was noted to have been given refill of her oral opioids on the morning of her ER arrival. As per Telfer & Kaya (2017), "there is evidence that an oral morphine protocol can be as effective as [intravenous] morphine." However, in this case, based on the provider's
assessment of the patient, the patient was not in severe pain that warranted inpatient level of care. The patient could have been safely monitored and treated at the observational level of care. Thus, inpatient admission was not medically necessary.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a history of hyperlipidemia and polysubstance abuse. The patient was sent to the Emergency Department (ED) from the clinic to rule out tuberculosis. The patient's chief complaints were cough and night sweats with occasional hemoptysis. The patient reported no history of tuberculosis (TB) exposure. The patient denied weight loss. The patient had a negative PPD in early 2019 and then in late 2019 she tested positive. The patient had been started on isoniazid (INH) in early 2019. The patient's vital signs at ED presentation were: temperature 98.6F, heart rate 87, respiratory rate 20, blood pressure 131/74 mm Hg, and oxygen (O2) saturation 98 % on room air. The patient's respirations were non-labored. The patient's lungs were clear to auscultation and her cardiovascular and abdominal exam were unremarkable. The patient's white blood cell (WBC) count was 11.7K, hemoglobin 12.7; liver function tests, electrolytes, BUN/Creatinine levels were all within normal limits. The patient's chest x-ray did not reveal any acute pathology. The patient was paced in airborne isolation to rule out tuberculosis. The patient was medically stable and discharged home.

Based on the review of the medical record and literature, inpatient admission was not medically necessary. The patient remained stable after admission. Given this patient's normal chest x -ray, the patient's chances of having active tuberculosis were not high. The patient could have been placed on Observation status. Sputum AFB smears could have been done every 8 hours. As it turned out, the patient's sputum smears were negative. The patient was treated with isoniazid/rifampin weekly regimen and was discharged home. The patient remained afebrile and was hemodynamically stable. The patient's workup in the Emergency Department showed low likelihood of active tuberculosis, and did not warrant inpatient admission. The patient's further diagnostic testing and management could have been done at the Observational level of care.
Thus, inpatient admission was not medically necessary.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Persistent Daytime Sleepiness

Treatment: Multiple Sleep Latency Testing (MSLT)

The insurer denied the multiple sleep latency testing (MSLT).

The denial was overturned.

This is a male patient who was being evaluated for persistent daytime sleepiness. It was reported that the patient had been experiencing this issue for several years. He denied a history of snoring. The patient sleeps multiple hours through the night despite that has Epworth Sleepiness syndrome (EDS); his Epworth Sleepiness Score is 6. There was no history of night time paralysis, hypnogogic hallucinations or Cataplexy.
The patient underwent an in Lab NPSG (nocturnal polysomnography).  AHI (apnea-hypopnea index) was 2.0.  Lowest O2 saturations were 85 %.  There was no evidence on OSA (obstructive sleep apnea) or RLS (restless leg syndrome) or desaturation.  Due to the patient's continued symptoms of EDS the patient's medical doctor (MD) is requesting a repeat NPSG with MSLT to rule out Narcolepsy.

Given the patient's history and negative NPSG, Narcolepsy is a possibility and needs to be ruled out.

The standard procedure for MSLT is to do it 1.5 to 3 hours after a NPSG.  MSLT is valid only if the NPSG demonstrates at least hours of sleep during the preceding night.  In addition a drug toxicology screen should also be negative.  Based on above the prior denial is overturned.

The carrier's denial of coverage for multiple sleep latency testing (MSLT) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chills, nausea, vomiting, and abdominal pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male.  He had presented emergently to the emergency department (ED) of the facility filing the appeal.  The patient reported chills, nausea, emesis and abdominal pain for 24 hours.  Diarrhea was also noted.  The patient had a history of diabetes, hypertension, hypercholesterolemia, tobacco abuse, asthma, duodenal ulcer, history of gastrointestinal (GI) bleeding, and Barrett's esophagus.  The patient evidenced tachycardia, hyperglycemia, and an elevated white count.  The patient had emesis in the ED, as well.  The computed tomography (CT) scan suggested thickening at the terminal ileum and other non-specific changes were noted.  A left lower lung nodule was also noted.  GI recommended an endoscopy and colonoscopy electively.  The patient improved and was discharged with follow-up. 

No, the proposed inpatient admission was not medically necessary. 

The care as provided was medically appropriate, but the level at which the care was provided was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care.  The patient had nausea, emesis, and diarrhea, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, anemia, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  The patient's colitis could have been managed at a lower level in its entirety.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Genetic Testing

Diagnosis: Prostate Cancer
Treatment: genetic testing
The insurer denied genetic testing. The health plan's determination is upheld.

The patient is a male who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 5 out of 15 cores. The clinical stage was T1c. An OncotypeDx test was ordered on the biopsy specimens. Medical necessity of the test is under review.

The Genetic Testing is not medically necessary for this patient. The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy (active surveillance versus (vs). treatment) in newly diagnosed low or low-intermediate prostate cancer. The American Urological Association (AUA) Guidelines on Clinically Localized Prostate Cancer, 2017 states, "Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up."

While Oncotype Dx may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Teeth out of alignment.
Treatment:  Braces.

The insurer denied the braces.  The denial is overturned. 

The patient is a female.  The request is for the orthodontic benefits.

Yes, the proposed braces are medically necessary. 

The patient has her upper lateral incisors (teeth #7 and #10) severely out of alignment in a buccal, or forward position.  This is going to make these teeth more prone to trauma and/or fracturing over time.  These teeth stick out in a forward direction, and this potential problem will be lifelong, unless the alignment of the teeth is corrected with braces.  This case has medical necessity.