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

Diagnosis: Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is overturned.

This is a patient who has chronic low back pain. She developed this pain after pulling a hatch while working on a boat about one year ago. Her pain is constant, aching, worse with sitting and putting on shoes and socks. Her pain level ranges from 2/10 to 9/10. She had tried physical therapy (PT) and epidural injection without improvement. The physical exam (PE) is unremarkable except tenderness to palpation (TTP) in the lumbar paraspinal region and 4/5 motor strength bilateral hip extension. Magnetic resonance imaging (MRI) revealed Modic type 1 and 2 changes in the lumbar spine. This patient was recommended to have Intracept Procedure from lumbar (L) 4-sacral (S) 1. At issue is whether the proposed health service or treatment, Intracept Procedure, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes, the Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrating the effectiveness of this intervention. This patient has persistent back pain consistent with vertebrogenic pain. She had failed extensive treatments including PT and epidural injections. Her pain is severe. Further interventions are medically necessary to improve her pain and functional level. Other potential treatment options are long-term use of medications (nonsteroidal anti-inflammatory drugs [NSAIDs], opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario. The Intracept Procedure is the appropriate next step intervention.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a male who presented electively for cardiac catheterization after an abnormal exercise test. There is a history of myocardial infarction, percutaneous intervention, hypertension, and hyperlipidemia. The creatinine was normal. He underwent a successful and uncomplicated percutaneous intervention of a right coronary artery (RCA) stenosis. He remained stable and was discharged.

The inpatient hospital admission was not medically necessary. This patient underwent successful elective and non emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization was not medically necessary. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is an adult who presented to the emergency room complaining of left leg pain and swelling. He also had a left fifth toe ulcer. Records indicated he was previously hospitalized earlier this year with similar complaints. He left against medical advice with oral antibiotics. Emergency Department (ED) documentation noted that physical exam findings included necrotic wound to the left distal aspect of the little toe with surrounding warmth but no significant erythema. There was positive edema with a blood pressure of 146/78. The patient had a prior history of left foot infection incompletely treated with a now progressive left foot pain and swelling. Aside from hyperglycemia, the patient was overall well in appearance. There were concerns for osteomyelitis with low suspicion for necrotic fasciitis. The assessment included worsening left toe/foot cellulitis with dry gangrene of the left fifth digit. Vascular surgery was consulted after the patient reported approximately 2 months history of worsening left toe wound. He was subsequently admitted to vascular surgery whereupon he was started on intravenous vancomycin and Zosyn. An insulin sliding scale was continued and he underwent angiogram/angioplasty via lower extremity access on the left. 

The Milliman Care Guidelines state that hospital admission may be indicated for those individuals diagnosed with cellulitis who have suspected necrotizing soft tissue infection. Records confirmed that there was suspicion of necrotic fasciitis of the left lower extremity, localized at the left small toe. Given the provided information, it was determined that the inpatient treatment was appropriate and within standard of care given the multiple issues that needed to be addressed. The patient had comorbidity of diabetes with the need for revascularization for limb salvage with evidence of cellulitis and necrotic tissue. Based upon the provided clinical information and Milliman care guidelines pertaining to cellulitis and surgical wound care of the foot, the inpatient treatment was appropriate and within the standard of care. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head pressure, weakness
Treatment: Air Ambulance Transport
The insurer denied: Air Ambulance Transport
The denial is upheld

The patient is an adult female who presented to the emergency ward with the complaint of head pressure, ringing in her ears, fatigue and generalized weakness. She was transferred to a higher level of care for neurological assessment.

The proposed treatment was not medically necessary.

The patient presented with non-specific complaints. The records indicate that the patient had already been assessed for her condition and completed a lumbar puncture two days prior to presentation. There was no documentation of any significant focal deficit, underlying neurological condition or abnormal diagnostic studies that required emergent neurological assessment (Ruskin, 2019). There was no documentation that the patient was medically unstable. She could have been safely and effectively transported by ground.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia. 
Treatment: Injectafer. 

The insurer denied Injectafer. The health plan's determination is overturned. 

The patient is a female with past medical history of iron deficiency anemia diagnosed with labs showing hemoglobin 11.5, hematocrit of 35.8, ferritin of 7, and iron 68. The patient was seen by her provider with the office note stating that the patient denied fatigue or anemia but the assessment and plan at the same visit noted the diagnosis of iron deficiency anemia with plan to repeat labs. 

Injectafer is medically necessary for this patient. 

Per the patient and her primary care physician (PCP), the patient did meet medical necessity criteria for Injectafer IV infusion. The patient was not on dialysis. The patient had a noninflammatory condition of iron deficiency anemia. The patient was not able to tolerate oral iron due to side effects and had taken 4 weeks of oral iron prior to her infusion. In summary, the requested Injectafer is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult male who presented to the medical center with abdominal pain, nine out of ten (9/10) in intensity. The patient was previously seen in the emergency room (ER) with similar complaints and according to ER notes, the patient underwent computed tomography (CT) angiogram and CT of the abdomen/pelvis - both of which were negative. The patient's past medical history is significant for end stage renal disease (ESRD), hypertension (HTN), congestive heart failure (CHF), psoriasis, pulmonary embolus, and gas gangrene.

The patient's initial blood pressure was 160/105, hemoglobin was 12, and blood urea nitrogen (BUN)/creatinine was 44/9.02. The patient's electrocardiogram (EKG) showed prolonged QT interval (a measurement made on an EKG used to assess some of the electrical properties of the heart), repeat CT of the abdomen/pelvis was negative, and abdominal ultrasound showed cholelithiasis. The patient was admitted and seen by cardiology and gastroenterology (GI). Esophagogastroduodenoscopy (EGD) showed gastric body inflammation and gastric reflux. The patient was treated with intravenous a proton pump inhibitor (PPI) and his blood pressure was addressed. The patient was discharged the next day in stable condition.

Reason for health plan denial: Admission of patient was not medically necessary (the patient could have been placed in observational status).

Reason for appeal: Inpatient admission was appropriate and supported by published clinical care guidelines (25th edition Milliman Care Guideline [MCG] criteria Gastroenterology GRG: MGGAS ISC GRG) Clinical Indications for admission to inpatient care: "Admission is indicated for one or more of the following: Gastroenterology condition, symptom, or finding for which observation care has failed or is not considered appropriate."

The proposed inpatient hospital admission was medically necessary.

The proposed treatment is medically necessary because "the needed care can only be safely given on an inpatient basis." This patient had multiple issues on presentation to the ER. He had severe hypertension and severe abdominal pain. He had just been to the ER two days before for abdominal pain. He is also a dialysis patient. With his complaint of eight to nine out of ten (8-9/10) abdominal pain along with his other comorbidities, his work-up could only be done safely as an inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral Arterial Disease (PAD)
Treatment: Vascular surgery (angioplasty) procedure codes 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37228, and 37229, and inpatient stay 
The insurer denied: Vascular surgery (angioplasty) procedure codes 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37228, and 37229, and inpatient stay 
The denial is upheld

The patient is a male with a remote history of smoking having quit more than 30 years ago. The patient underwent right common femoral artery endarterectomy and right external iliac artery stenting and right proximal superficial femoral artery (SFA) stenting for disabling right leg claudication. The patient is maintained on Plavix (but is not on a statin for unclear reasons despite having a documented mild dyslipidemia and a history of peripheral arterial disease [PAD]).

Based on the answer to question #1, both the requested procedure codes and inpatient medical stay are not medically necessary for this patient at this time. The issue that led to the health plan's denial is that conservative therapy, which in the case of claudication is an exercise program and sometimes medication such as cilostazol has not been completed for this patient from the office visit. The provider stated in his addendum that the patient "has tried walking and exercising for over 6 months but this has not helped." It is unclear to me what form of exercise program the patient has engaged in as it is not described in the provider's documentation. Also, it is not chronologically possible for the patient to have engaged in a program for 6 months from the office visit.
The most recently published American Heart Association/American College of Cardiology (American Heart Association [AHA]/American College of Cardiology [ACC]) guidelines on the management of patients with lower-extremity PAD include 4 recommendations supporting exercise therapy for patients with PAD. The AHA/ACC guidelines gave supervised exercise treadmill training a Class I recommendation supported by a Level of Evidence A on the basis of multiple randomized clinical trials showing the efficacy of supervised exercise treadmill training to improve claudication onset time (COT) or distance (COD), peak walking time (PWT) or peak walking distance (PWD), and other clinically meaningful functional outcomes.
Endovascular intervention for the right lower extremity is not warranted at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure 
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure 
The determination is overturned.

This is a male patient who has a history of back pain. His pain is in the lumbosacral junction region, with a pain level of 8/10, worse with flexion, walking and exercise. He had tried pain medications, physical therapy (PT), transcutaneous electrical nerve stimulation (TENS), and chiropractic manipulation without improvement. His physical exam (PE) was unremarkable with a negative straight leg raise and facet loading tests. Magnetic resonance imaging (MRI) shows severe lumbar (L) 5-sacral (S) 1 degenerative disease with extensive Modic changes.
At issue is whether the Intraosseous Basivertebral Nerve Ablation Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. The Intraosseous nerve ablation procedure (Intracept) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. His lumbar spine magnetic resonance imaging (MRI) revealed extensive L5-S1 Modic changes, which is a diagnostic criteria for vertebrogenic pain. He had tried PT, TENS and chiropractic manipulation without improvement. Further interventions are necessary to improve his pain. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the Intracept procedure is the next step intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure 
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure 
The determination is upheld.

This is a male patient with low back pain. The pain has been present for over a year. The patient has tried Motrin and Tylenol. The pain impacts his activities of daily living (ADLs). The pain can be as high as 8 out of 10. Prior treatments have included chiropractic care, medication management, as well as physical therapy. Magnetic resonance imaging (MRI) of the lumbar spine reported Modic changes at lumbar (L) 5-sacral (S) 1. There is a request for Intraosseous Basivertebral Nerve Ablation Procedure. At issue is whether Intraosseous Basivertebral Nerve Ablation Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation Procedure 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 complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Dementia
Treatment: Home Health Care (HHC) - Level 2 Personal Care Services (PCS), per 15 minutes increase to 84 hours/week 
The insurer denied the HHC - Level 2 PCS, per 15 minutes increase to 84 hours/week. 
The denial is upheld.

The patient is a female with medical history notable for Alzheimer's dementia and arthritis. The patient was approved for 51 hours/week of level 2 personal care services (PCS). The patient and her care team requested an increase to 84 hours/week, and this request was denied by the health plan. This denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented times three. She has modified independence for cognition. She is able to direct her personal care needs and meals and able to describe her daily routine and emergency plan. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation, stairs, shopping, and transportation. She requires extensive assistance for managing finances and medications. For her activities of daily living (ADLs), she requires extensive assistance for bathing, dressing upper body, and dressing lower body. She requires limited assistance for hygiene and toilet use. She is independent for walking, locomotion, toilet transfer, bed mobility, and eating. She is occasionally incontinent of urine (less than daily), and she is continent of stool. Compared with prior assessment, she did not show any significant worsening in her functional performance. A task tool associated with the most recent assessment recommended 30.5 hours/week to meet her personal care needs.

The health plan's determination is upheld.

The requested health service/treatment of home health care (HHC) - Level 2 PCS, per 15 mins increase to 84 hours/week is not demonstrated to be medically necessary for this patient.

The patient is currently approved for 51 hours/week. The task tool associated with the UAS recommends 30.5 hours, so there is already a significant margin above the recommendation. The patient is able to direct her own care. She has functional needs, but her personal care hours should be sufficient to cover them. The only reference to unmet personal care needs is from a recent fall in the shower; however, she does have personal care time allotted to bathing so she should have a personal care aide present for this activity. There is no additional documentation regarding personal care needs that are not being met by the current hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gambling and impulse disorder
Treatment: Intensive Outpatient Mental Health Services
The insurer denied Intensive Outpatient Mental Health Services. 
The health plan's determination is overturned. 

The patient is a male who presented for intensive outpatient program (IOP) level treatment to address a gambling and impulse disorder and comorbid mood disturbances best characterized as persistent depressive disorder and attention deficit hyperactivity disorder (ADHD) -combined type. The patient self-referred with the encouragement of family and his treating clinician in the context of severe psychosocial stress within the family constellation and ongoing psychosocial stressors related to his gambling with consequences, as well as worsening symptoms of depression. Medications and outpatient sessions with telemedicine had been ineffective prompting the step up to IOP level services.

Intensive Outpatient Mental Health Services was medically necessary for this patient.
The requested benefit of IOP Level Treatment is clinically appropriate and medically necessary in this case scenario. Moreover, the patient had severe symptoms of gambling addiction, mood and attentional disorders and severe psychosocial stressors with poor impulse control that did warrant the IOP level of care during the time interval under review. The IOP services were medically necessary with the continued psychiatric management of the symptoms of the gambling disorder and associated symptoms of comorbid conditions and psychosocial stressors within the primary support and other psychosocial domains. The patient's severe psychosocial stressors within the primary support and social environment domains did clearly necessitate the admission and continued structure and monitoring of an IOP level service with regard to the intensity, structure and duration of treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Syncytial Virus (RSV)
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Overturned

The patient is a female with history of respiratory syncytial virus (RSV) bronchiolitis responsive to albuterol and strong atopic family history, who presented to the emergency room (ER) with increased work of breathing and wheezing. Per history, the patient was taken to an urgent care center on the day of admission with fever, rhinorrhea, cough, and increased work of breathing. There, she was given albuterol/Atrovent x2 and dexamethasone. She was sent to the ER via Emergency Medical Services (EMS) for further care due to persistent respiratory distress.

The health plan's determination is overturned.

In this patient, inpatient admission was medically necessary. Though the patient improved quickly after admission, she presented to the emergency room in respiratory distress with tachypnea and accessory muscle use in her breathing. Despite repeated, frequent bronchodilator use over several hours, intravenous steroids, and magnesium sulfate, she continued with tachypnea and oxygen saturations decreased from that at presentation (98 to 93%). The patient is documented to have been persistently tachypneic (respiratory rate 48) two hours after completion of the magnesium infusion. At that point in time, she still required hourly albuterol nebulizers. It is not recommended that a patient with a requirement of such frequent bronchodilator treatments be discharged home.
Although this patient does not yet have a diagnosis of asthma, she has a history of bronchospasm with RSV which was responsive to albuterol and strong atopic family history (multiple siblings with asthma). Prior to admission, the patient received multiple medically appropriate treatments (bronchodilator, steroids, and magnesium sulfate) in an effort to improve her respiratory distress without significant results. Given that she was persistently symptomatic (tachypnea with respiratory rate 48, and oxygen saturation 93%), decision to admit after the aforementioned treatments was appropriate and medically necessary.