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

Diagnosis: Emesis, upper abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male with cyclical vomiting who presented with three days of abdominal pain and vomiting. He was hemodynamically stable, with mild hypertension and tachycardia, and was afebrile. He had a normal white blood cell (WBC) count; labs were consistent with dehydration. The patient's lipase was elevated, but imaging was negative for pancreatitis. The patient was hydrated and treated with anti-emetics. On day #1, the patient was feeling better, dehydration was improved, and he was tolerating Jell-O and juice without abdominal pain or vomiting. On day #2, the patient was tolerating solids and liquids without abdominal pain, but complained of vertigo, for which he was given meclizine. The patient was discharged on day #3.

The acute inpatient hospital stay was not medically necessary.

The hospital stay was denied as acute inpatient stay, as there was no evidence of intractable vomiting, sepsis, prolonged dehydration, prolonged inability to tolerate oral intake or prolonged electrolyte abnormalities. As the patient had a history of cyclical vomiting related to cannabis with similar admissions, and had no evidence of hemodynamic instability, intractable vomiting, need for prolonged nothing by mouth (NPO), sepsis, prolonged dehydration or electrolyte abnormalities, a lower level of care was appropriate. In addition, as of day #1, the patient was tolerating oral intake without abdominal pain or vomiting, was feeling better and his dehydration was improved. Therefore, a lower level of care was appropriate and acute inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis (ALS)
Treatment: Radicava ORS (oral suspension)
The insurer denied: Radicava ORS (oral suspension)
The denial is overturned

The patient is an adult male with a diagnosis of amyotrophic lateral sclerosis (ALS). He has scored a 2 or more on every Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS) category except for walking up stairs. The provider wishes to prescribe Radicava. The request was previously denied as patient had not scored a 2 or higher on every category on the Amyotrophic Lateral Sclerosis Functional Rating Scale.

Radicava is medically necessary.

Radicava is Food and Drug Administration (FDA) approved for amyotrophic lateral sclerosis (ALS) of all stages. It is the first therapy to be approved for amyotrophic lateral sclerosis in decades and studies have shown that it is effective in slowing down progression by 33%(percent). Withholding this medication will only cause patient to progress faster. For these reasons, Radicava is medically necessary and in the best interest of patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

Diagnosis: Lower back pain.
Treatment: (procedure code 64628) to treat low back pain.

The insurer denied coverage for (procedure code 64628) to treat low back pain.  The denial is upheld.

This patient has chronic low back pain. He has had Physical therapy, heat/ice therapy, an Epidural Steroid injection, and Medial branch blocks.  His medication trials have included Tylenol, ibuprofen and muscle relaxants.  His magnetic resonance imaging (MRI) shows herniated discs at lumbar (L)4-L5 and L5-sacral (S)1. He has Modic changes at L3. L4. L5 and S1. The request is radiofrequency (RF) ablation of the basivertebral nerve (BVN) at L3 and L4. Surgical consultation is not documented.

In sum, the publications to date have been company sponsored and had methodology flaws. There is no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Urits et al. (5) also commented on the need for more research on this promising technique: "reproducible large RCTs (randomized control trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP (chronic lower back pain) and improve the quality of life of chronic low back pain patients in the near future."

In sum, this procedure is NOT likely to be more beneficial than the standard of care.

In summary, the denial of procedure (procedure code 64628) to treat low back 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 risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Renal colic. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is overturned. 

This case involves an adult diagnosed with kidney stones, insulin-dependent diabetes, and hypertension who presented to the emergency department (ED) complaining of right-sided flank pain along with nausea, vomiting, dysuria, urgency, and frequency. The emergency department report stated that the patient's symptoms began the day prior with reports of difficulty sleeping overnight. Upon arrival, the patient was febrile with a temperature of 101.1 degrees. She had tenderness to the right costovertebral angle (CVA) and flank area consistent with renal colic. A computed tomography (CT) of the abdomen/pelvis found mild to moderate right hydronephrosis secondary to a 7 millimeter (mm) distal right kidney stone just prior to the ureterovesical junction (UVJ). The patient's laboratory testing showed a creatinine at 1.61. The remainder of the studies were relatively unremarkable other than mild leukocytosis with a white cell count of 13.3 and a subtle left shift noted by 87.6% segmented neutrophils. The patient was admitted to medical services to be seen by urology and underwent a successful right-sided ureteral stent placement. She did well, remained hemodynamically stable, and was subsequently discharged.  

The Milliman Care Guidelines (MCG) state that there are clinical indications for admission to inpatient care. While the information provided for the review noted that the patient was hemodynamically stable, and did not have acute kidney injury stage II, acute renal failure stage III, bilateral obstruction, adduction with a single functioning kidney, transplant kidney with obstruction, severe pain requiring acute inpatient management, severe or persistent vomiting, urinary tract infection, or the need for intravenous hydration support despite observation care. The patient did require a stone removal procedure that needed inpatient admission given her comorbidities of obesity, hypertension, and insulin-dependent diabetes that placed the patient at an increased risk factor for complications. It was therefore determined that the inpatient stay was within the standard of care. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ovarian cyst
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. On postoperative day 2, if the patient is passing flatus and tolerating a regular diet she is discharged home. This patient was managed according to the standard of care.

The inpatient hospital admission should be approved based on Milliman Care Guidelines (MCG) Laparotomy.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: Braces (comprehensive orthodontic treatment)
The insurer denied coverage for braces (comprehensive orthodontic treatment)
The denial is upheld.
 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) score as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 9 points on review by internal reviewers.

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

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 braces (comprehensive orthodontic treatment) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral Palsy
Treatment: 24 Physical Therapy and 24 Occupational Therapy Visits
The insurer denied the 24 physical therapy and 24 occupational therapy visits.
The denial is upheld.

The patient is a teenaged female with a history of cerebral palsy, developmental delay, and seizure disorder. She lives in the community with family. She is blind in both eyes and nonverbal. She is on supplemental oxygen and on continuous tube feeds via gastrojejunostomy tube. She is restricted from intake by mouth. She is incontinent of bladder and wears an incontinence brief. She has been followed by home health services. She has generalized weakness, fine motor deficits, limb contractures (at the bilateral shoulders, wrists, hands, knees, and ankles), impaired endurance, and pain issues. She has been dependent for all care and mobility including transfers. She is passively transported via wheelchair with total assist. She has been receiving occupational and physical therapies for at least 3 years, which has included passive range of motion and family/caregiver training. The therapists have worked on attempting to engage the patient to show some participation in activities such as rolling.

The health plan denied coverage of the service under review, indicating that the service is not medically necessary as they do not support a skilled plan of care. The denial is being appealed.

The requested 24 physical therapy and 24 occupational therapy visits are not medically necessary.

There are no indications in the records of any functional or health goals requiring ongoing skilled physical therapy or skilled occupational therapy services. The patient has already undergone therapies where caregivers were provided training to assist the patient. The patient otherwise has not shown any capacity to actively and meaningfully participate in therapies towards functional or other clinically meaningful goals. Additional formal therapy services are not expected to improve the patient's outcomes based on the patient's conditions, history, and examination findings, including her developmental delay, contractures, and history of total dependence for all care and mobility.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient hospital admission.
The health plan denied: Inpatient hospital admission.
The determination is: Upheld.

The patient is a female with a medical history of gestational diabetes status post Cesarean section. She presented to the emergency department on with left-sided chest pain worse with deep inspiration and radiating to her epigastrium, and nausea. She had undergone a cesarean section on earlier that month. Her vital signs were notable for a rapid heart rate of 103 beats per minute and a rapid respiratory rate of 26/minute. The physical examination was notable for soft, nondistended abdomen with epigastric tenderness. The labs showed an elevated white blood cell count of 10.6, a low hemoglobin of 11.0 and hematocrit of 33.9, an elevated platelet count of 427, and an unremarkable comprehensive metabolic panel. A computed tomography scan of the chest with angiogram showed no pulmonary embolism. A computed tomography scan of the abdomen and pelvis showed cholelithiasis, but otherwise no acute abdominal or pelvic pathology. An ultrasound of the right upper quadrant showed cholelithiasis without secondary signs of acute cholecystitis. She was treated with intravenous cefotetan. She was made nothing by mouth (NPO) status. She felt well, without nausea or vomiting, chest pain, or dyspnea; her pain was well controlled. Her labs showed a normalized white blood cell count, a low hemoglobin of 10.3 and hematocrit of 32.7, an elevated aspartate aminotransferase of 166, an elevated alanine aminotransferase of 152, and an elevated alkaline phosphatase of 133. She underwent an uncomplicated laparoscopic cholecystectomy. She denied nausea, vomiting, chest pain, and dyspnea; she was tolerating a diet. She was discharged with a plan for Surgery follow-up.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. The patient was assessed to have possible cholecystitis. However, she did not have evidence of ascending cholangitis, gallstone pancreatitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care [1-8]. Additionally, there was no persistent hemodynamic instability or other complications. The patient did have an uncomplicated cholecystectomy and did not experience postoperative complications such as pneumonia, sepsis, or bile leak which might require the inpatient level of care. There was no contraindication to performance of imaging, and then cholecystectomy, after presentation. Her liver enzymes were elevated, but there was no acute liver failure, choledocholithiasis, or other concerns resulting in additional imaging or workup [8]. The interventions performed, including labs, monitoring, imaging, and laparoscopic cholecystectomy, could have been performed in sequence after presentation without the inpatient level of care. For these reasons, the inpatient level of care is not supported.
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 woman who presented to the emergency department (ED). She was 8-days status post open cholecystectomy. She had complaints of worsening abdominal pain. At the time of presentation, the patient had a heart rate of 77/minute with otherwise normal vital signs. The ED evaluation revealed a normally healing incision with diffuse abdominal tenderness. Lab data identified a normal white blood cell (WBC) count, hemoglobin of 11, and normal liver enzymes and bilirubin. A computed tomography (CT) scan identified changes of recent cholecystectomy and an area of hypoperfusion of the liver (related to her recent surgical procedure and the need for ligation of bleeding liver). She was admitted to the hospital with the diagnosis of uncontrolled pain.

The inpatient hospital admission was not medically necessary.
The submitted records support that this the patient presented to the hospital following an open cholecystectomy procedure 8-days earlier. Her complaint was that of abdominal pain. She was admitted to the hospital for pain management. Imaging with a computed tomography (CT) scan did not identify post-surgical pathology that required intervention. Lab data was normal. She was treated with parenteral analgesia that was converted to oral analgesia. She did not require acute surgical treatment and remained stable throughout the period of monitoring.
Her condition responded promptly and favorably to the provided therapy and she was able to start a diet and had appropriate pain management. The care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperhidrosis
Treatment: Botox 200-unit vial
The insurer denied coverage for Botox 200-unit vial.
The denial is upheld.

The patient is an adult with hyperhidrosis "all over the body." The patient has only failed over the counter (OTC) Drysol and has not tried any prescription medications. The requested medication is Botox axillary injection.  

There is no documentation provided that the patient has failed traditional therapies for hyperhidrosis which are known to improve the condition. Per the documented history, the patient suffers from hyperhidrosis "all over the body" and as such would be ideally treated with systemic agents for hyperhidrosis rather than localized topical therapies or localized axillary Botox. Treatment with commonly used systemic mediations are known to improve hyperhidrosis. One such example is the conventional treatment oxybutynin, which has been shown to be effective for hyperhidrosis. Wolosker, et al writes in "A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis" that "Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life." (5)

The conventional agents are appropriate agents for the treatment of the patient's hyperhidrosis. Conventional therapies are not more likely to cause adverse reactions and the documentation provided does demonstrate a contraindication to use of these medications. The conventional medications should be tried and failed prior to initiating Botox, which would only be useful for localized axillary hyperhidrosis. After review of the documentation provided, there is no documentation provided that would justify the patient requiring treatment with Botox prior to the conventional alternatives such as oxybutynin.

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 Botox 200-unit vial is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder
Treatment: Consumer Directed Personal Aide Services (CDPAS) for A total of 168 hours/week
The insurer denied the CDPAS for a total of 168 hours/week.
The denial is overturned.

This elderly female has medical conditions that include cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder, anxiety, osteoarthritis, diabetes, hypothyroidism, anemia, abnormal gait, and urinary incontinence. Denial of Consumer Directed Personal Aide Services (CDPAS) for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The patient needs assistance with ADLs (activities of daily living). She is frequently incontinent and cannot change or dress independently. A statement from her provider notes her condition is worsening. She has a history of multiple falls. She is unable to use her left arm after a shoulder injury. She uses the commode every 2-4 hours and cannot transfer without assistance. She needs to be cleaned and changed frequently during night due to incontinence. A statement from her children notes she lives alone. She has difficulty walking and cannot get to the bathroom or out of chair or bed when her aide leaves. She wakes up 5-6 times per night and needs assistance with going to the bathroom. 

The proposed treatment is medically necessary. 

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. Denial of CDPAS for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The statement provided indicates that the patient's condition is deteriorating. She needs assistance with ADLs. She has urinary incontinence and requires assistance with transferring and toileting every 2-4 hours. The information provided supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS for 70 hours/week is insufficient to support her continuous needs. The proposed CDPAS for a total of 168 hours/week, split shift is medically necessary.