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

Diagnosis: Injury to the left hand. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a history of hypertension and hyperlipidemia. He presented to the emergency room (ER) with complaints of left hand pain after using a saw to make furniture. An x-ray of the left hand was done. There were fractures of the first distal phalanx, second proximal, middle, and distal phalanx, and third middle phalanx. A sterile dressing was applied and an incision and drainage (I&D) was done. The patient was given 1000 milligrams (mg) of intravenous (IV) Cefazolin, 50 micrograms (mcg) of IV Fentanyl, and an intramuscular (IM) tetanus, diphtheria, and pertussis (Tdap) vaccine. He was admitted for further care. He underwent a left second and third digit external fixation and first digit soft tissue advancement. The procedure was uncomplicated and the patient tolerated it well. He was transferred to the post anesthesia care unit (PACU) in stable condition. The patient received 24 hours of IV Ancef. He was discharged with instructions to take 81 mg of oral (PO) aspirin a day (QD) and a 10 day course of PO Augmentin. He would follow up with the surgeon on an outpatient basis. 

The medical record demonstrates the patient sustained an isolated injury to his left hand. He underwent timely surgical intervention to his injured three fingers. He had removal of bone and coverage to the thumb area. He had reduction and application of external fixators to index and long finger. He underwent irrigation and debridement. The operative report did not describe extensor tendon repair. 

The procedure was of limited duration (approximately 1 1/2 hours). There was no blood loss. The patient did not require treatment for other medical conditions. There were no post-surgical complications. He had undergone the procedure approximately 12 hours after admission. 

The post-surgical physician record stated: "Pain well controlled, no concerns, dispo [disposition] planning" 

The records show that the patient's vital signs were stable. There was no evidence of fever, infection, bleeding nor wound problems. 

His clinical condition did not substantiate necessity for the acute care services. That is, non complicated post-surgical course with limited morbidity.  There were no reported extenuating circumstances to support the level of care provided. 

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

The inpatient hospital admission is not considered medically necessary for this patient. 

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

Diagnosis: Sarcoidosis of the lung

Treatment: Acthar Gel

The insurer denied coverage for Acthar Gel 

The denial is upheld

This male with history of sarcoidosis diagnosed by eye exam and computed tomography (CT) scan findings, asthma and gastroesophageal reflux disease (GERD). The patient also has history of obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP). The patient was being treated with steroids for many years for his ophthalmic sarcoid. The patient was initially on 20 milligrams (mg) weekly and reduced to 12 mg weekly.

The patient was seen by provider in the office. The patient was afebrile and hemodynamically stable. Some dry cough and hoarseness of voice. Physical exam was unremarkable.

The patient had chest CT done twice within five years which revealed some mild scarring. A repeated CT revealed no significant change from prior CT. No lymphadenopathy seen.

Pulmonary function tests (PFT's): 

First- Restrictive pattern indicated by total lung capacity (TLC) 4.05 66 percent (%), diffusing capacity of lung for carbon monoxide (DLCO) 46 %;

Second- Restrictive pattern indicated by TLC 4.33 71%, DLCO 55%;

Third- Restrictive pattern indicated by TLC 4.04 66%, DLCO 44%.

The patient's provider wanted to prescribe Acthar Gel for sarcoidosis as he felt the patient would not tolerate increased dose of prednisone.

The patient was on Symbicort, Singulair for asthma.

There was no indication for Acthar Gel in this patient. His sarcoid was stable. No change in PFT's. CT also stable.

The indications for Acthar Gel include infantile spasm and acute exacerbation of multiple sclerosis (MS) in adults. The patient does not have any of these conditions.

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

The insurer's denial of coverage for Acthar gel for sarcoidosis of the lung is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Chronic Pain Syndrome/Chronic groin pain
Treatment: Pain Management-PNS(Peripheral nerve stimulator)
The health plan denied the Peripheral nerve stimulator as experimental/investigational. 
The health plan's determination is upheld in whole. 

The patient is  post herniorrhaphy inguinodynia. Treatments tried include physical therapy, medications and interventional pain procedures including a trial of dorsal root ganglion stimulation. Implantation of lead(s) for peripheral nerve stimulation is proposed.
The reviewer has upheld in whole the health plan's determination.
The proposed health service or treatment is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
A review of peripheral nerve stimulation states "Peripheral nerve stimulation and peripheral nerve field stimulation are emerging as a viable neuromodulatory therapy in the treatment of refractory pain. Although the technology of percutaneous stimulation has been available for decades, recent advancements have broadened the number of indications. Success of treatment revolves around identifying the correct patient population, and the selection and placement of the appropriate electrodes and implantable pulse generators. Most results to date have come from case reports and retrospective studies. However, given the promising outcomes in reducing otherwise medically refractory pain, future randomized controlled studies are needed to assess this emerging technology" [1].
A review of the approach to the patient with chronic postoperative groin pain states "patients with chronic pain refractory to conservative measures may be considered for surgical intervention. Triple neurectomy remains the most definitive and accepted remedial operation performed and provides effective relief in the majority of patients" [2].
A systematic review of peripheral nerve stimulation states "Peripheral nerve stimulation was studied in 14 randomized controlled trials (RCTs) for a variety of painful conditions (headache, shoulder, pelvic, back, extremity, and trunk pain)....Peripheral nerve stimulation has moderate/strong evidence. Additional prospective trials could further refine appropriate populations and pain diagnoses" [3].
Reliable evidence shows that the consensus among qualified objective experts regarding the inherent nature of peripheral nerve stimulation for the management of post herniorrhaphy inguinodynia is that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment and is not likely to be more beneficial than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Chronic Pain Syndrome/Chronic groin pain
Treatment: Pain Management-PNS(Peripheral nerve stimulator)
The health plan denied the Peripheral nerve stimulator as experimental/investigational. 
The health plan's determination is overturned.

The patient has left groin pain and genitalia numbness that began 5 years prior following inguinal hernia repair. The patient has undergone multiple injections without benefit, including but not limited to, pudendal nerve block, pudendal nerve radio frequency, dorsal root ganglion(DRG) Stimulation trial without improvement, left ilioinguinal/iliohypogastric block at anterior superior iliac spine (ASIS), left inguinal canal hydrodissection block, spermatic cord block, left pubic tubercle lateral block and suspensory ligament block. He has also had ongoing physical therapy and noted resistance to medications. 
The reviewer has overturned in whole the health plan's determination.
Percutaneous neuromodulation therapy is likely to be more beneficial than any standard treatment(s). The patient  developed left groin pain and genitalia numbness following hernia repair over 5 years ago. Per documentation review he has tried numerous injections, physical therapy, and medications with limited improvement. As noted in "Prospective, Multicenter, Randomized, Double-Blinded, Partial Crossover Study to Assess the Safety and Efficacy of the Novel Neuromodulation System in the Treatment of Patients With Chronic Pain of Peripheral Nerve Origin" three months after randomization to treatment (with treatment #45 and control #49) there was a statistically higher response rate (38% vs 10%) in the treatment group. Even during the partial crossover period there was, again, a significant improvement in pain with active stimulation compared to baseline. This type of neuromodulation has been proven to be safe and effective and for this particular patient, who has tried numerous injections, therapy, and medications, it is appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Chronic Pain Syndrome/Chronic groin pain
Treatment: Pain Management-PNS(Peripheral nerve stimulator)
The health plan denied the Peripheral nerve stimulator as experimental/investigational. 
The health plan's determination is upheld in whole. 

This is a  patient with a diagnosis listed as G89.28 other chronic postprocedural pain. According to the treating providers documentation, the patient has chronic intractable groin pain present for several years with sharp stabbing pain and numbness and tingling. The patient has tried physical therapy, radiofrequency ablation, surgery, injections, nerve blocks, dorsal root ganglion stimulator trial, over-the-counter nonsteroidal anti-inflammatory drug (NSAID)s and pain medications. The provider is now requesting to perform an implantation of percutaneous peripheral nerve stimulator (PNS), which was denied. 
The reviewer has upheld in whole the health plan's determination.

There is no evidence that the proposed service or treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. According to evidence based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, percutaneous peripheral nerve stimulator (PNS), "Not recommended, including several terms and device variations including percutaneous neuromodulation therapy (PNT), peripheral nerve stimulation (PNS), and peripheral nerve field stimulation (PNFS). Available systems include but are not limited to:  Sprint Peripheral Nerve Stimulation System (SPR Therapeutics, Cleveland, Ohio)  StimQ Peripheral Nerve Stimulator (Stimwave Technologies Incorporated, Ft. Lauderdale, FL)  StimRouter Neuromodulation System (Bioness, Inc., Valencia, CA). Overview: While it has been suggested that peripheral nerve stimulation (PNS) may augment or be a monotherapy for pain treatment, there are still gaps in knowledge requiring further research. Data on these techniques has been limited to case reports, retrospective reviews, and small case series, primarily for occipital nerve stimulation for chronic migraine headache."
This treatment is considered experimental and investigational and requires additional studies. There is no evidence found in the peer-reviewed medical literature suggesting that percutaneous peripheral nerve stimulation is likely to be more beneficial than any other standard treatments for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Severe diarrhea. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is modified. 

This is a pregnant female patient who presented to the Emergency Room (ER) with severe diarrhea. She was 19.3 weeks pregnant. She had been recently diagnosed with  clostridium difficile (C. diff) and received a 10 day course of Flagyl. Symptoms did not significantly improve. A repeat stool sample was negative. Her physical examination was unremarkable. Vital signs were stable. She was hemodynamically stable with no evidence of leukocytosis. She was admitted for intravenous (IV) hydration and a Gastroenterology (GI) consult. During the admission, the patient was treated with IV magnesium sulfate for a magnesium level of 1.8. PlasmaLyte was given. Oral vancomycin was started. Progress note on day 2 of admission documented improvement in the patient's condition. Magnetic Resonance Imaging (MRI) did not show any anomaly. Progress note on day 3 of admission documented that the diarrhea resolved. Per Internal Medicine, the patient could be discharged. Per GI, the patient could be discharged. Progress note on day 4 of admission documented the patient was stable. She was discharged later that day.

This patient presented with diarrhea. Her C. diff had already been treated and stool culture was negative. There was no evidence of fulminant colitis, hypotension or shock, ileus, or megacolon. While there were concerns about a megacolon and due to the severity of the diarrhea and evidence of dehydration, admission was medically necessary to hydrate the patient, correct the electrolyte imbalance, and rule out megacolon. However, by day 2 of admission, the patient's condition had improved, and the MRI did not reveal any anomaly. There was no evidence of fulminant colitis and the patient was stable and could have been discharged home that day on oral vancomycin.

The health care plan acted reasonably in part.

The inpatient hospital admission on day 1 of admission is considered medically necessary for this patient. Continuous admission was not.

The insurer's denial of coverage for the inpatient hospital admission is modified. Allow day 1 of admission but uphold denial of day 2 to day 4.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

Diagnosis: acute cholecystitis  
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a male with a recent history of biliary duct stenting for choledocholithiasis. The patient presented with a complaint of epigastric abdominal pain that radiated to the right upper quadrant. The patient was found to have acute cholecystitis and was admitted for magnetic resonance cholangiopancreatography (MRCP) and likely laparoscopic cholecystectomy. The patient underwent MRCP confirming cholecystitis and no bile duct obstruction. He underwent an uneventful laparoscopic cholecystectomy and was discharged.

The inpatient admission was not medically necessary. This is a patient with cholecystitis who underwent laparoscopic cholecystectomy (an outpatient surgery) who was well enough after to surgery to go home that same night. This was documented in the chart and the only reason that the patient stayed after surgery was that he had no ride home. Prior to surgery, there was no evidence of choledocholithiasis, the patient was hemodynamically stable, and had no reasons for an inpatient stay. Outpatient laparoscopic cholecystectomy is a well-established practice that has been demonstrated to be safe in multiple studies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet. 
Treatment: Braces. 

The insurer denied the Braces. 
The denial is upheld. 

The patient is a female.  The request is for dental benefits for orthodontic (braces) treatment.  Orthodontic records were created by the attending physician -- photos and x-rays. 

No, the proposed treatment of orthodontic therapy (braces) is not medically necessary.
There is no documentation to support a diagnosis of malocclusion that would require orthodontic therapy (braces).  While the Attending physician notes an overjet, the photos and x-rays do not exhibit / support any malocclusion in this patient. 

Orthodontic therapy (braces) is a complex, significant and invasive treatment that repositions teeth in the bone.  It is only undertaken as a corrective measure when there is a diagnosis of some type of misalignment / malocclusion taking place.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemic hyperosmolar state. 

Treatment: Inpatient level of care.

The insurer denied coverage for the inpatient level of care. 

The denial is overturned. 

This is a male patient with diagnoses of Type 1 diabetes mellitus (DM), gastroparesis, and hypothyroidism. He was seen in the emergency room (ER) with concerns of nausea, vomiting, and elevated blood sugars at home. The patient had been on an insulin pump but it stopped working, so he started injecting regular insulin. His blood sugar in the ER was 622. In the ER, he was treated with intravenous (IV) fluids and insulin. His nausea was treated with Zofran. He was admitted for elevated blood sugars, nausea and vomiting, and malfunction of his pump. He was admitted, and gastrointestinal (GI) specialists and endocrinology specialists were consulted. He was discharged in a stable condition.

Per Rewers, A. (2018), "Diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), lactic acidosis (LA), and hypoglycemia are acute and potentially life-threatening complications of diabetes..."      

Type 1 diabetes is a serious systemic disorder with diverse presentations and very high morbidity; for this reason, the condition is best managed by an interprofessional team of healthcare professionals. Over the long term, the vast majority of patients with this disorder will develop blindness, adverse cardiac events, end-stage renal disease, neuropathy, and in some cases, premature death.

Stoner G. D. (2017), "Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose and hyperosmolarity with little or no ketosis ...Identification and treatment of underlying and precipitating causes are necessary."

The patient was admitted as an inpatient to the Medical/Surgical unit for HHS following dysfunction of his insulin pump. The patient has a severe medical illness (Type 1 DM) and he presented with elevated blood sugar, nausea, vomiting, and dehydration and malfunction of his pump. This led to severely elevated blood sugars. Acute inpatient admission was the only way to treat him adequately.

The health care plan did not act reasonably and with sound medical judgment, and in the best interest of the patient. Based on this individual's clinical presentation, it is evident the patient required admission, and a denial of coverage is not appropriate.      

Based on review of the patient's clinical information, due to his status of uncontrolled blood sugars, nausea and vomiting, and insulin pump malfunction, requiring treatment with insulin and IV therapy, an inpatient stay was appropriate and medically necessary.
                                                         
The insurer's denial of coverage for the inpatient level of care is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe developmental delay and tracheomalacia
Treatment: Private Duty Nursing 12 Hours x 7 Days
The insurer denied the Private Duty Nursing 12 Hours x 7 Days.
The denial is overturned.

The patient is a female child with medical history significant for severe developmental delay and tracheomalacia with resultant severe obstructive sleep apnea. She requires ventilatory support at night during sleep via a Trilogy ventilator with back-up rate 10 and 0.5 L (liters) supplemental oxygen for desaturations. With this support, she sleeps 10 to 12 hours per night. In the absence of this ventilatory support, she regresses and suffers significant daytime sleepiness. The current request is to maintain skilled nursing services 12 hours nightly to manage her care while she is on the ventilator.

This child lives with her guardians. She attends school. Her skilled nursing needs include management of the Trilogy ventilator and monitoring of her respiratory status during sleep with adjustments in supplemental oxygen as needed for desaturations.

Yes, the requested skilled nursing hours remain medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." (1) Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1)

This school-aged severely developmentally delayed child has a number of medical problems as a result of and in addition to her severe tracheomalacia and obstructive sleep apnea, including need for ventilatory support at night. Without the ventilator support, she experiences daytime sleepiness that causes further delays. Skilled nursing services are necessary to monitor oxygen saturation, add supplemental oxygen when her saturations drop below 94%, and assist in maintaining a patent airway. While intermittent night time intervention may be manageable by trained layperson caregivers, the continuous monitoring (with necessary interventions) that this child requires cannot be safely provided on a routine basis night after night. The requested skilled nursing services 12 hours nightly, 7 nights/week remain medically necessary and appropriate, consistent with definition of medical necessity, and with the current standard of care.