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

Diagnosis: Cough, Shortness of breath, pleuritic chest pain
Treatment: Inpatient admission

The Inpatient admission was not medically necessary. The patient could have been treated at the observation level of care.

The patient is a female with COPD (chronic obstructive pulmonary disease), not asthma.  She was admitted for asthma and discharged home.  She had a history of diabetes and hypertension. She had continued cigarette abuse daily and had been smoking cigarettes one to two packs a day for many years. She had a history of dry cough with a little yellow sputum for three days and some pleuritic chest pain. She was morbidly obese with a BMI of 43.8. 

In the ER, the patient's chest was clear, and the chest x-ray revealed no acute disease. Na (sodium) was 139, K (potassium) was 4.4, HCO3 (bicarbonate) was 25. Troponin was normal. RA (room air) O2 (oxygen) was 91% and then increased to 94%. Heart rate was 101, and she was in sinus rhythm.  BUN (blood urea nitrogen) was 14.5 and creatinine was 1.13. WBC (white blood count) was 8,400, and Hb (hemoglobin) was12.2.  Platelet count was 226,000.  

The patient was ambulatory and gait was normal.  She was treated with IV Solu-Medrol and a sliding scale of insulin.  She was started on PO (oral) Zithromax.

On the second day, the patient's WBC (white blood count) was 8,800 and the Na was 139. K was 4.5. The RA O2 saturation was 95% and heart rate was 77/minute. 

IV Solu-Medrol was switched to PO Prednisone with a taper. Because of the steroids, the patient's glucose was elevated, and she required periodic coverage with insulin.  She was discharged home.

The patient's admitting diagnosis was an exacerbation of acute asthma. She had no wheezing.  Her chest was clear, and the chest x-ray revealed no acute disease. She was never intubated and had COPD, not asthma. The listed admitting diagnosis was not consistent with her presentation.

The patient was in no distress in the ER, and gait was normal. Besides smoking cigarettes, one to two packs/daily for many years, she continued to smoke cigarettes every day. The WBC was initially normal, but was slightly elevated as expected with IV Solu-Medrol.  The steroids increased the glucose. She was morbidly obese with a BMI of 43.8 (morbid obesity is a BMI of 40 or greater).  She improved, and on day after presentation, the RA O2 saturation was 95%.  The heart rate was 77/minute. She could have been discharged after observation in the ER. She could have been discharged on PO Zithromax for COPD/ bronchitis with slight yellow sputum. 

Inpatient acute care was not medically necessary, nor was it provided. The benefit plan denial for inpatient acute care for was appropriate, and the denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with history of COPD (chronic obstructive pulmonary disease). He presented to the ER with worsening SOB (shortness of breath) and chest pain. The patient was treated for similar episodes one week prior to this episode in the ER. 

The patient was diagnosed with COPD exacerbation. The patient received nebulization treatment and IV steroids in the emergency room.  The patient was admitted to acute in hospital level of care for continued frequent nebulizations, as well as IV steroids. 

The next day, the patient's breathing improved. The patient's wheezing improved. The patient was transitioned to oral prednisone. The patient was continued on the same oral steroids treatment and nebulizations on the following day. The patient was discharged home with steroid tapers and nebulization treatments.

Although the patient had failed outpatient treatment within one week prior to this admission, the patient's condition improved with emergency room care as well as observation level of care. The patient could have been discharged home with oral steroids as well as nebulizations the day after presentation, as he was hemodynamically stable, and was able to tolerate oral diet. His condition has improved significantly with IV steroids.  Thus, the acute in hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crown with open margins
Treatment: Filling crown, tooth #9
The proposed treatment is medically necessary. 

The provider states that the existing crown on tooth #9 has open margins. This will allow decay to start undermining the crown. A new crown is needed with closed margins to prevent decay and loss of the tooth. The tooth has no infection present and the existing root canal filling is described as being sufficient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lung nodule
Treatment:  code 78815, Positron Emission Tomography and Computed Tomography (PETCT)

The insurer denied the code 78815, positron emission tomography and computed tomography (PETCT).  The denial was upheld.   

This is a male patient, who was hospitalized after experiencing a snowboarding accident.  A computed tomography (CT) scan of the chest, abdomen, and pelvis was performed that revealed a mild compression fracture of T11 and an incidental finding of a 0.6 mm nodule in the right upper lung and a 1.5 x 3.2 cm left pre-vascular lymph node.  A thoracic surgeon consulted on the patient.  The patient reported having night sweats for over a year, without weight loss.  Hematology/Oncology Specialist consulted on the patient indicating sarcoidosis or lymphoma could not be completely ruled out.  A request for a positron emission tomography and computed tomography (PETCT) was made to further evaluate the lingular node.  If the levels were normal and there was reasonable uptake, the plan was to pursue with a biopsy.

According to literature, such as Freeman & Matto (2019) article, unexplained localized lymphadenopathy can be followed up with a repeat imaging, such as computed tomography (CT) scan 3 to 4 weeks to check if the lymphadenopathy resolves or improves.  And if the lymphadenopathy does not resolve or improve, the recommended next step is to obtain a biopsy.  However, this observation period is not recommended if the patient is suspected to have a high risk for malignancy.  The Freeman & Matto (2019) article states that if the patient's clinical history, physical exam and epidemiological clues indicate that the patient has a high risk for malignancy or serious illness, then the patient should proceed with a biopsy immediately without waiting.  As for this patient's case, this unexplained localized lymphadenopathy was discovered incidentally and was without clinical signs or symptoms that alerted high-risk for malignancy.

While literature, such as the Sin KM1 et al. (2017) article, supports that the "2-(fluorine-18) fluoro-2-deoxy-d-glucose positron emission tomography with computer tomography (FDG-PET/CT) is useful in detecting extranodal sites during staging, treatment response assessment or recurrence detection in patients with lymphoma", literature support for its use on patients with incidental lymphadenopathy is lacking.  As to date, this patient's lymphadenopathy has not been observed or confirmed by biopsy that it is malignant and requires PET/CT scan workup.  Thus, the requested procedure, Positron emission and computed tomography (PETCT) is not medically indicated for this patient's case.  

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

The carrier's denial of coverage for code 78815, Positron emission tomography and computed tomography (PETCT), a special picture of the body from head to thighs is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bell's palsy

Treatment: Botox 100 Unit Vial

The insurer denied Botox 100 Unit Vial. The denial was reversed.   

This is a female patient with history of Bell's palsy secondary to zoster which has caused her right eye brow and lid to suffer from ptosis. It was reported that the patient's right eye has a 5 mm right eyelid ptosis with a lid fissure height of 5-6 mm (left lid fissure 11 mm).  The patient was unable to use her right eye causing her to have no depth perception which would place her at a higher risk for falls and motor vehicle accidents. She was being treated with Botox which alleviated her symptoms. Alternatively it was recommended that she have surgical intervention to lift her eyebrow and lid. The patient was not interested in pursuing surgery due to the increased risks associated with it. A request for Botox 100 unit vial was made.

Eye brow ptosis has been an FDA approved indication for over 15 years.  In this patient's case, the brow ptosis was not cosmetic, but it was functional because the brow drooping made her upper lid cover her pupil, and she could not see out of her right eye.  There was no other appropriate treatment, aside from Botox, except for surgical intervention.

The health care plan did not act reasonably, or with sound medical judgment, or in the best interest of the patient.  The patient had been treated with Botox on multiple occasions for years, and this allowed her to remain a functional part of society.  There is no other treatment for the patient's condition aside from surgery.  The patient was not interested in surgery.  

Based on the above, the medical necessity for Botox 100 Unit Vial is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder 
Treatment: Home Health Care 

The patient is a male with the diagnosis of autistic spectrum disorder, developmental delay and asthma. Based on the assessment provided in the medical records of this case, the patient also has behavioral issues that place him at risk for self-injury. Evaluation by a nurse from the NYS Department of Health recommended an on-site personal care assistant for the patient. The health plan has deemed this aide to not be medically necessary, which is the issue under review. 

The health plan's determination is overturned. It is simply impossible for the primary caregiver to be able to engage in one-on-one supervision of a child that is developmentally delayed, with unsafe behaviors, inability to comprehend the need for hygiene including fecal and urinary incontinence 24 hours per day. This in turn places both the patient and the primary caregiver at increased risk for the patient's potential for self-injury or injury to others, particularly as he grows. While didactic approaches to reducing these type of behaviors are available, they cannot circumvent the ability of the primary and sole caregiver to remain vigilant and attentive to the needs and actions of a child without the ability to self-govern their actions 24 hours/day. 

Based on the patient's inability to master activities of daily living that are appropriate to his age, and by definition involve social interactions with behavioral consequences that, because of his autism and developmental delay, place him at risk for self-injury, the requested personal care assistance services are indicated.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System / Neuromuscular Disorder
Home Health Care

The patient is a female with past medical history of hypothyroidism, anemia, frequent falls, left eye blindness, depression, dementia, psychosis, chronic back pain, left knee pain with osteoarthritis and diabetes mellitus type 2 who had been assigned PCA services at 10 hours/day, 7 days/week to total 70 hours/week. The patient had an assessment tool performed last fall and was repeated in the beginning of the year. There was a change in assistance needed for task of managing finances, otherwise there was no change in level of assistance for all other tasks. The patient had a fall when ambulating to the bathroom and fell and hit her head. She was hospitalized with chest pain and discharged the same day. There was an adverse determination letter sent stating PCA services would continue at 10 hours/day, 7 days/week for a total of 70 hours/week. The patient's pain management specialist wrote a letter stating the patient needed help with shopping, dressing and walking and needed an increase in PCA service hours. The patient's primary care provider wrote a letter indicating that the patient needed 24 hour home care services due to worsening senile dementia with wandering at night and combativeness causing increased risk for self-injury.

The health plan's determination is upheld.

The requested increase in person care aide level 2 services to 12 hours per day, 7 days a week (split shift) for a total of 168 hours per week is not medically necessary for this patient.
According to the most recent assessment tool performed there was no change in activities of daily living (ADLs) or instrumental activities of daily living (IADLs) except for managing finances from the prior assessment. The letters from pain management and the primary care provider did not support the need for 24 hour PCA Level 2 services in split shifts. There are concerns over the patient wandering and having self-injury which is considered safety monitoring and supervision which are not stand alone tasks which additional hours are not provided for. There is not medical necessity documentation for need for ADLs or IADLs in the overnight hours, or outside the hours that were previously assigned. Per the most recent assessment completed the patient continued to be self-directing and continued to be able to activate a personal emergency response.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This is a male patient who was admitted to this inpatient substance detoxification treatment in this hospital in late 2018 for detoxification from alcohol and illegal substances.  He had withdrawal symptoms including tremors, sweats, nausea, yawning, sleeping problems, joint pain, irritable mood, anxiety, and teary eyes and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 17.  He was heavily drinking and using substance. He had a toxicology report that was positive for opiates.  He had a medical history of hypertension and diabetes.  He had multiple past inpatient detoxification treatments.  He lacked sober supports, coping skills, and needed to improve identification of triggers/stressors.  He was started on a Librium protocol, which was completed during this admission and then transferred to stepped down to substance rehabilitation.
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient had been heavily drinking and using substances. He is at risk for overdose and severe life-threatening withdrawal symptoms.  He had active withdrawal symptoms on admission and continued taking detoxification medication with Librium. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings. This was evidenced by the fact that he continued to use large amounts of alcohol and substance despite medical issues and multiple past reported detoxification treatments. He required detoxification medication to modify withdrawal and needed 24-hour treatment. He was at risk for worsening, life-threatening withdrawal symptom such as delirium. These complicated withdrawals can occur three to four days after alcohol use; therefore, he required the entire admission in this hospital. He also lacked sober supports and coping skills. 

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain
Treatment: 22899 - Percutaneous intradiscal radiofrequency thermocoagulation
The health plan should cover the 22899 - percutaneous intradiscal radiofrequency thermocoagulation.

The patient is a female with a history of chronic low back and bilateral lower extremity pain. She has previously undergone a micro diskectomy. She continues to have severe low back and leg pain. The patient has seen multiple neurosurgeons and has been offered lumbar fusion as her only alternative treatment.

The patient is a female who previously has had a laminectomy and diskectomy.  She continues to have low back pain. She is on moderate to week opiates, tramadol.  She has seen multiple neurosurgeons and has been offered a lumbar fusion.  She is looking for an alternative to a fusion.  The Intracept procedure (interosseous basivertebral nerve ablation) here is not an intradiscal procedure. It is a new 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 use in patients with significant Modic type I or type II vertebral endplate changes.  The patient is quite young. The alternatives, spinal fusion, do not have good long-term results in the literature.  Spinal fusion in young patients is typically not recommended and is sought to be avoided.  It is a very invasive procedure with high morbidity and poor outcomes.  In fact, most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.  Therefore, the options are limited.  

Spinal cord stimulation is an alternative. However, it has not been shown to have excellent results in primarily axial mechanical/discogenic type pain.  Therefore, the Intracept procedure is a reasonable option.  It is FDA-approved.  Randomized studies are available.  Two year outcomes have proven high success.  It is not an intradiscal procedure, which have not been shown to have good results in the literature.  

Since there is no Medicare-approved code (CPT code) for this procedure, the health plan has chosen a code for an intradiscal procedure. However, this does not accurately describe the requested procedure. Given that the alternatives do not show favorable outcomes in the literature, the requested Intercept procedure is medically appropriate and should be covered.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain
Treatment: 22899 - Percutaneous intradiscal radiofrequency thermocoagulation
The health plan should not cover 22899 - percutaneous intradiscal radiofrequency thermocoagulation.

The patient is a female with history of low back pain. She had a previous L45 microdiscectomy. The patient has also attempted PT (physical therapy) and ESI (epidural steroid injection) in the past, and she takes clonazepam, Klonopin, Flexeril, steroids, and tramadol for pain. 

The patient's exam reveals no focal deficit. The patient is a smoker. MRI (magnetic resonance image) shows mild disc protrusion at L45 along left L4 nerve root. The patient was recommended L4 and L5 vertebral bodies. 

The proposed procedure is still not considered within the standard of care for patients with this diagnosis. In addition, there is no indication on the MRI report that Modic changes are present. The patient does not have a surgical lesion noted on MRI, and there are no Modic changes noted. The proposed treatment is not deemed medically appropriate, as it is not considered within the standard of care by most spine surgeons.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain
Treatment: 22899 - Percutaneous intradiscal radiofrequency thermocoagulation

The health plan should cover the proposed treatment, percutaneous intradiscal radiofrequency thermocoagulation.


The patient is a female. She is status-post (s/p) an L4-5 microdiscectomy on 04/11/2018.  She has persistent low back pain and leg pain.  She has tried epidural injections, pain management, and physical therapy. 

On 07/18/2019, the patient's neurological examination showed muscle tone was normal and strength was normal in all four extremities.  She had intact sensory exam to light tough.  She had normal gait.  Balance was intact.  Current medications at the time included methylprednisolone, Klonopin, clonazepam, methocarbamol, and tramadol.

At L5-S1, the patient's magnetic resonance image (MRI) showed left laminotomy changes with disc bulge and small superimposed left foraminal disc protrusion.  The protrusion moderately narrows the left neural foramen and mildly impinges on the existing left L5 nerve root.  At L4-5, there was a mild disc bulge and left foraminal disc protrusion with mild impingement on the exiting left L4 nerve root.  There was mild scoliosis.

The records also include nerve conduction studies that show chronic L4-L5 radiculopathy.  There are pain clinic records showing L4-5 and L5-S1 lumbar epidural injections were performed in 2018.  Injections did are documented as yielding some pain relief and improvement in functionality per Dr. Jahanbakhsh.  An injection by Dr. Jahanbakhsh was noted to yield sustained 60% pain relief.  The note by Dr. Jahanbakhsh indicated that the patient was going to follow up with Dr. Langer to discuss surgical options.

Dr. David Langer recommended an Intracept procedure to treat chronic vertebrogenic pain, CPT 22899.

The patient is status-post (s/p) an L4-5 microdiscectomy.  She has persistent low back pain and leg pain.  It is documented that she has tried epidural injections, pain management, and physical therapy.  The provider has identified the patient as a reasonable candidate for the procedure.  The procedure has been shown to lead to significant improvement of pain and function in patients with chronic vertebrogenic related low back pain (Khalil et al., 2019) in a recent prospective randomized trial.  Therefore, approval of the requested service is recommended.