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

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

The patient is a female who presented to the emergency department (ED) with shortness of breath and chest tightness. She also was complaining of leg edema and cough. Her shortness of breath started 1.5 weeks prior to presentation with orthopnea and worsening leg swelling. Sleeping on the right side felt better. The left leg was more swollen than right. The patient has a history of hypertension (HTN), morbid obesity, HLD (hyperlipidemia), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and history of deep vein thrombosis (DVT) / pulmonary embolism (PE) with pregnancy. She also has history of myasthenia gravis (MG) and tobacco abuse disorder. She is on pyridostigmine for MG.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with worsening orthopnea and LE (lower extremity) edema. The patient has a history of CHF, and this is not her first admission for heart failure. Her condition upon presentation was stable, and her BP was elevated, but improved quickly. She was not in severe distress, her O2 (oxygen) saturation was unremarkable, and her venous blood gas did not reveal any hypoxia. Her CXR (chest x-ray) revealed only mild worsening of CHF. Her ECG (electrocardiogram) did not have acute ischemic changes or cardiac arrhythmia. The patient had low Na (sodium) in her blood, but that was corrected easily with the first dose of intravenous Lasix. The patient responded well to diuresis and was discharged home next day.
The patient also has multiple co-morbidities, such as HTN, uncontrolled diabetes, obesity and smoking. However, these problems were chronic and were treated with preadmission medications.
Based on above, an inpatient admission was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar and Hypertrophic Cardiomyopathy (During Pregnancy)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult, gravida one (G1), female who was transferred from an outside facility for "pre-delivery optimization" at 37 weeks, one day.  The patient had presented at 29 weeks with shortness of breath and a pre-syncopal episode at which time she was hospitalized and diagnosed with hypertrophic cardiomyopathy based on an echocardiogram and was discharged.  Her history was also significant for gestational diabetes which was noted to be well controlled on a low dose of metformin on an outpatient basis at the time of the present admission.  In addition, she did not complain of any cardiac or other symptoms at the time of admission.  
The patient's vital signs, labs, and and physical exam were unremarkable and there was no documentation of signs of heart failure.  She was admitted and a repeat transthoracic echocardiogram was performed which was unchanged from the prior exam.  The metformin dose was increased.  She was discharged home on hospital day number three.  

The health plan contends that the admission was not medically necessary due to absence of abnormal vital sighs, unstable heart rate or blood pressure, electrolyte abnormalities, mental status changes, need for ongoing intravenous fluids, vomiting, abnormal blood sugars, or documentation that patient education and care could not have been completed under observation care.  The facility contends that heart failure is a major contributor to maternal morbidity and mortality, that she had syncope during pregnancy and shortness of breath, and a high risk pregnancy and that the admission was medically indicated, reasonable, and consistent with evidence-based practice.

The proposed inpatient hospital admission was not medically necessary.
Although the patient had echocardiographically diagnosed hypertrophic cardiomyopathy, she had no significant heart failure signs on her echocardiogram.  Her vital signs were normal and there was no evidence of acute exacerbation of her disease.  The cardiologists did not recommend any treatment that would require hospitalization, and consult and echocardiogram could have been obtained on an outpatient basis prior to decision to hospitalize.  The patient's diabetes was documented to have been under good control on an outpatient basis and there is no documentation of hyperglycemia in the range that would merit hospitalization.  No other co-morbidities were documented that would merit hospitalization.  Therefore the admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
treatment: Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral. 
The health plan's determination is upheld.

This is a male patient who is diagnosed with back pain. Records indicate that the patient was recommended to undergo the Intracept procedure, which was denied by the health plan.

Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral 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 is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. It was noted the patient has failed treatment including medications, physical therapy and epidural steroid injection. magnetic resonance imaging (MRI) showed multilevel lumbar disc bulges and degenerative changes including canal stenosis and foraminal stenosis as well as Modic type I endplate changes at L (lumbar) 5-S (sacral)1. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
treatment: Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral. 
The health plan's determination is upheld.

The patient is a male with chronic lower back pain (LBP) for greater than 6 month. His referring physician notes chronic LBP causing significant impacts on his activities of daily living (ADL), including moving from sitting to standing. The pain radiated to his right buttock and thigh. The patient rates his pain on Visual Analog Scale (VAS) on average 7-8/10, with 80 % of the pain in his low back and 20% in his right leg. There was no complaints of weakness or sensory deficits. He has received multiple interventions including physical therapy, transforaminal epidural steroid injections and medications including muscle relaxants and opioids.

Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral 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 limitations due to the chronic LBP and he is taking Opioids and muscle relaxants to manage the pain. The requesting physician notes that the pts (patient's) pain is significant and limits activities of daily living (ADL) but there is no ODI (Oswestry Disability Index) score. Additionally, the magnetic resonance imaging (MRI) report notes Modic changes but no STIR (Short Tau Inversion Recovery) imaging was performed. The results of the most recent TESI (Thoracic Epidural Spinal Injection) were not reported to determine if the patient received any relief. He also reported at least 20% radicular pain with nerve root impingement. Additionally, the facet arthropathy was not addressed. It is hard therefore to determine with the information presented if this patient meets the criteria demonstrated in studies that predict he will benefit from the procedure.
Therefore, based on the information provided, the requested procedure is not likely to be more beneficial than standard treatment for this patient. In this case, better documentation of this patient's limitations, including detailed physical examination findings, and documentation of the MRI STIR findings are needed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
treatment: Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve, Including all Imaging Guidance, First 2 Vertebral Bodies, Lumbar or Sacral. 
The health plan's determination is upheld.

This is a male who has low back pain with occasional radiation to the right buttock and right lateral thigh. His pain is worse from sitting to standing as well as with flexion. Pain level is 8/10. He had tried physical therapy (PT) and pain medications including Vicodin and oral anti-inflammatory without adequate improvement. Physical exam (PE): right lumbar paraspinal tenderness, decreased range of motion (ROM) of lumbar spine, pain with extension and flexion. Positive kemp Test and positive facet loading. An magnetic resonance imaging (MRI) revealed mild spinal stenosis of L (lumbar) 3-4 and L4-5, a broad based disc bulge and facet arthropathy at L5-S (sacral) 1 and Increased disc height loss of L5-S1 with progression of Modic type 1 endplate changes. This patient was recommended for bilateral L5-S1 transforaminal epidural injections and L5-S1 basivertebral nerve ablation. 

The proposed procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's medical condition or disease.
Thermal Destruction of Intraosseous Basivertebral Nerve was designed to treat low back pain from vertebral body. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. This patient has low back pain with radiating pain to right buttock and right lateral thigh. Physical exam (PE) revealed Positive kemp Test and positive facet loading, which is indicative of facetogenic pain. An magnetic resonance imaging (MRI) revealed mild spinal stenosis of L3-4 and L4-5, a broad based disc bulge and facet arthropathy at L5-S1. Current clinical studies supported the efficacy of Thermal Destruction of Intraosseous Basivertebral Nerve 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple myeloma
Treatment: Continued Inpatient Hospital Admission
The insurer denied: Continued Inpatient Hospital Admission
The denial is upheld

The patient is an adult female with multiple myeloma who has undergone multiple courses of therapy. Magnetic resonance image (MRI) showed T (thoracic) 7 compression fracture and cord compression. The patient underwent T6-T8 instrumented fusion with radiation therapy. The patient developed sepsis and required antibiotics. The patient had a prolonged hospitalization. 
The notes indicate the patient developed chemotherapy induced thrombocytopenia. The patient required transdermal patches for pain as well as other oral pain medications.

The proposed inpatient hospital admission was not medically necessary.

The patient did not require any treatment that would necessitate continued acute inpatient hospitalization.
The patient did not require any treatments that required continued acute inpatient hospitalization. This includes any treatment that could not be performed in an outpatient setting. The patient was able to take oral pain medication as well as transdermal pain medication which could be provided in a lower level of care. The patient did not have any acute neurological issues or any other findings that warranted acute inpatient hospitalization. All dates in question were not medically necessary and could have been provided in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Pain.
Treatment: MRI of Right Knee (73721).
The insurer denied: MRI of Right Knee (73721).
The denial is upheld.

This patient is an adult male with right knee pain. He had discomfort medially. It was worse with walking. The patient received an injection of cortisone.  The physical examination was significant for tenderness and positive McMurray. The physician recommended magnetic resonance image (MRI) of the right knee.  The patient returned to the physician and felt better. He was referred to physical therapy (PT) and was provided with Meloxicam.

The proposed treatment was not medically necessary.
A magnetic resonance image (MRI) is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes magnetic resonance image (MRI) should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed.  The performance of the magnetic resonance image (MRI) should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary.

The records show no conservative treatment had been provided. A consultation was completed but no specific course of physical therapy (PT), rest, nor a brace were recommended. 

The Official Disability Guidelines, and AIM Guidelines, criteria also note a magnetic resonance image (MRI) is not indicated unless a course of conservative treatment had been provided.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Outpatient procedure (64628 x 1) and coverage for the requested service/treatment.
The insurer denied coverage for outpatient procedure (64628 x 1) and coverage for the requested service/treatment.
The denial is overturned.

This is an adult with chronic low back pain who is trying to avoid more invasive treatment (lumbar fusion) and who meets Food and Drug Administration (FDA) approved criteria for the requested Intracept treatment, which is likely to be more beneficial at this time. 

There are RCT (randomized controlled trials) that show its effectiveness at two years. There is another follow-up study where it was recommended that patients cross over to the treatment arm due to effectiveness early on (see provided references). 

Intracept is medically indicated in patients who have - A history of low back pain of at least 6 months duration; and failed to respond to at least 6 months of non-surgical management; and an MRI (magnetic resonance imaging) demonstrated Modic Type 1 or Type 2 changes at one or more vertebrae from L (lumbar)3 to S (sacral) 1; and - Activities of daily living that are limited by persistent low back pain; and - All other reasonable sources of pain have been ruled out. 

The patient is a good candidate for the requested procedure. The patient's symptoms and the MRI (magnetic resonance imaging) evidence of Modic type II (fat) endplate changes confirm that the patient suffers from the type of back pain that has been shown to benefit from this treatment. 

The procedure is the best available treatment for the patient at this time. The patient is a relatively young adult who has failed conventional treatment, including physical therapy, medications, facet injections, radiofrequency ablation, and activity modification. Given that the alternative options (lumbar fusion), have not shown to have favorable responses for axial low back pain in the literature and is much more invasive, this less invasive procedure may be more beneficial to this patient at this time. 

In summary, the denial of outpatient procedure (64628 x 1) and coverage for the requested service/treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting.
Treatment: Inpatient Stay.
The insurer denied the Inpatient Stay.  
The denial is upheld.

The patient is a female gravida (G)2 para (P)0 abortion (A)1 who was at 14 weeks gestation (by last menstrual period [LMP]). This patient presented to the Emergency department with abdominal pain and vomiting. The patient was complaining of left lower quadrant pain since midnight with nausea and vomiting. She had known asthma and history of chlamydia, gonorrhea, and trichomonas. The main complaints were nausea and vomiting with abdominal pain. She was noted to have stable vital signs with blood pressure of 151/68, pulse of 88, temperature of 97.2 Fahrenheit (F) and respiratory rate of 19. She was noted to have a normal exam with the exception of abdominal tenderness in all quadrants with no costovertebral angle (CVA) tenderness. She had no guarding or rebound to support a surgical abdomen. The patient was reported to be unable to tolerate by mouth (PO) for the past 5 days. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

Based upon a review of the medical records and the recommendations of the American College of Obstetricians and Gynecologists (ACOG), there would not have been medical necessity for inpatient stay.

In this case, the patient could have received safe and appropriate evaluation and treatment at a lower level of care. Based on an evaluation of the patient's presentation, the patient's evaluation by lab evaluation and consultation with the obstetrics/gynecology (OB/GYN) and gastrointestinal (GI) specialist, the care can be completed at a lower level of care. This is supported by the usual management of a patient who presents with nausea and vomiting in pregnancy with normal imaging by magnetic resonance imaging (MRI) excluding abdominal process and normal ultrasound for fetal viability and location of pregnancy. The patient had normal labs and vital signs. There was no acute abdominal exam with negative rebound and guarding. The patient could receive intravenous (IV) hydration with antiemetics and electrolyte replacement with IV fluids under a lower level of care status. Pain can also be managed at a lower level of care. This is in agreement with the recommendations of ACOG. In this case, the patient could have been safely and appropriately treated at a lower level of care and would not have required acute inpatient level of care for her management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent 300 mg/2 mL subcutaneous pen injector
The insurer denied the Dupixent 300 mg/2 mL subcutaneous pen injector.
The determination is upheld.

The patient has atopic dermatitis (AD). The patient's neck, hands, arms and legs are affected. He has tried and failed Neo-Synalar and clobetasol. He has also failed tacrolimus ointment. The medication Dupixent is under review for medical necessity.

The requested health service/treatment of Dupixent is not medically necessary for this patient.
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the health plan's preferred medications are effective treatments for the management of atopic dermatitis (1, 2).
Within the peer-reviewed literature, in 2018, Gerbens et al writes "methotrexate (MTX) and azathioprine (AZA) seem to be effective and safe as maintenance treatments in moderate-to-severe AD up to 5 years" (3) Shah et al 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk" (4). There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis (5-8). There are no unique clinical circumstances to this particular patient that would make the requested medication medically necessary. The patient has no true contraindications to the use of the preferred medications. The preferred agents, such as methotrexate, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.