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

Diagnosis: Rhinovirus/enterovirus
Treatment: Inpatient hospital admission
The insurer denied covered for the inpatient hospital admission.
The denial is overturned.

This is a male child with a history of multisystem inflammatory syndrome in children (MISC). He was sick with one day of fever, coughing and a decreased appetite. He was noted by his mother to have a decrease in his urine output. When his coughing and increased work of breathing worsened his mother brought him to the emergency room (ER) for an evaluation. 

In the ER he was noted to be in respiratory distress with increased work of breathing, retractions, and wheezing. On physical exam his pulse oximeter was 94% and the child had diffused wheezing upon auscultation of the chest, retractions, and prolonged expiration. He was treated with three treatments with DuoNebs, Decadron, magnesium sulfate and an intravenous (IV) fluid bolus. Following treatment, he continued to have wheezing and increased work of breathing. Blood testing showed a low serum bicarbonate demonstrating a metabolic acidosis. A chest x-ray was unremarkable, and a respiratory viral panel was positive for the rhino/enterovirus. When his wheezing was noted to persist, he was treated with 2 additional albuterol nebulizer treatments and then he was switched to continuous albuterol for one hour and the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus and metabolic acidosis for continued treatment with continuous albuterol.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for an acute episode of wheezing, metabolic acidosis and difficulty breathing. When he did not respond to treatment in the ER and he was noted to have persistent wheezing and labored breathing and retractions, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with continuous albuterol. He was not stable enough to be safely discharged. 

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

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

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied the Wegovy.
The denial is overturned.

The patient is an adult female with obesity and type 1 diabetes. The request for Wegovy is under review. The prior request was denied coverage by the health plan, because approval on criteria requires a failure to lose at least 5% of body weight through at least six months of lifestyle modification alone, and trial of at least six months of Orlistat or intolerance or contraindication to Orlistat, and documentation of current height and weight. The provider is appealing this determination.

The patient's weight was 194.8 pounds with a height of 5 feet 4 inches with calculated BMI (body mass index) of 33.41 at consultation with nutritionist. Her weight was 196 pounds after 6 months. After six months of treatment with Wegovy, her BMI (body mass index) improved to 26.9 with reduced glucose fluctuations. She has tried and failed Qysmia and Belviq. She has contraindications to Contrave and Xenical. She has been off Wegovy for two months with weight of 179 pounds and a BMI (body mass index) of 30.6.

The requested Wegovy is medically necessary.

This request is for Wegovy for the treatment of obesity. The prior request was denied coverage by the health plan because approval on criteria requires a failure to lose at least 5% of body weight through at least six months of lifestyle modification alone, and trial of at least six months of Orlistat or intolerance or contraindication to Orlistat, and documentation of current height and weight.

This patient met with a nutritionist and despite that had weight gain. She has tried and failed multiple other weight loss medications. She successfully lost weight on Wegovy and had improvement in glucose levels on Wegovy. She has regained weight off of Wegovy with weight of 179 pounds with a BMI (body mass index) of 30.6. Orlistat is not an appropriate alternative as it is less potent in terms of weight loss as compared to Wegovy and would not be expected to have the same positive impact on glucose levels. The use of Wegovy in this clinical situation with a current body mass index of 30.6 is consistent with the Endocrine Society guidelines on the management of obesity. Without Wegovy, this patient will be at increased risk of the complications of untreated obesity, including hypertension and hyperlipidemia. Therefore, the requested Wegovy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries-Brain Injury/concussion. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient is an adult female who is status post a fall of several steps who presents to the emergency department for evaluation. She reports loss of consciousness. Patient denies taking any blood thinners. Physical exam reveals a scalp hematoma with an otherwise unremarkable physical exam. A computed tomography (CT) scan of the head showed a small frontoparietal contusion. Neurosurgery evaluated the patient with recommendations for admission with neurochecks every 2 hours, Keppra 500 milligrams (mg) twice a day for 7 days and repeat CT head scan the next morning. Patient was admitted to the trauma service stepdown unit / intermediate unit. Repeat CT scan of the head showed resolution of the previously identified frontoparietal contusion. Neurosurgery reviewed the images and agreed that the patient was appropriate for discharge the next day. 

No, the requested health service/treatment of Inpatient Admission was not medically necessary for this patient. 

The patient is status post fall several steps presents to the emergency department for evaluation. She reports loss of consciousness. Physical exam reveals a scalp hematoma and an otherwise unremarkable physical exam. CT scan of the head showed a small frontoparietal contusion. This patient has no risk factors of intracerebral hemorrhage besides the mechanism of injury. She does not take any blood thinners. Her Glasgow Coma Scale (GCS) on arrival is 15. Her initial CT scan of the head scan showed a frontoparietal contusion without a subdural or epidural hematoma component. Her repeat CT head scan showed near resolution of the contusion and the patient was discharged. The patient's care could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke like symptoms

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This adult female patient has past medical history of hyperlipidemia and intracranial hemorrhage (ICH) and was seen in the emergency department (ED) with left sided shaking, left sided weakness, and left facial droop. She was given intravenous (IV) Keppra and then oral maintenance dosing. The patient had no further episodes. She was seen by Neurology for code stroke as she had an episode of left sided shaking and weakness. The assessment is stroke like symptoms. The patient has a past history of stroke with left sided weakness and had seizure activity at home. She was given IV Versed by emergency medical services (EMS). The neurology progress note showed no abnormalities. The computerized tomography (CT) scan of the head showed old left temporoparietal infarct encephalomalacia and no occlusion. 

The patient was noted to have seizures in the past with similar symptoms as seen in this clinical setting. There was no evidence of recurrent seizure while in care, new stroke, or unstable vital signs. There was no reason for inpatient hospital level of care. The patient could have been watched in the observation level of care setting.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the 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: Hemoptysis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a past medical history significant for metastatic renal cell carcinoma with metastasis in the lungs, adrenal glands, and lymph nodes who underwent treatment for that and developed pneumonitis. She presented to the hospital with hemoptysis and a fever.
The patient stated that she initially had a dry nonproductive cough that became more bothersome. She had one episode of hemoptysis. On that day, the patient underwent a computed tomography (CT) scan of the chest that was performed and demonstrated no evidence of pulmonary embolism. It showed no infiltrates, however, revealed progression of the disease with a worsened right mass with compression of the bronchi and a pleural effusion. She was evaluated in the emergency department and was discharged home with a prescription for Z-Pak. The patient noted that over the course of 2 days the paroxysmal cough became worse. Therefore, she was referred to the hospital again for a bronchoscopy. 
The patient was admitted to the hospital for evaluation by a pulmonologist.
During the hospital stay, the patient underwent a bronchoscopy. This study demonstrated near complete (90%) obstruction of the lower bronchus intermedius from extrinsic compression. The patient underwent balloon dilation up to 8 millimeters (mm). The bronchoscopy revealed right lower lobe and right middle lobe bronchi obstruction. There were mucous plugs in the right upper lobe posterior segment and right middle lobe, which were suctioned. The patient received treatment with Zosyn for what was considered post obstructive pneumonia. Subsequently, she was transitioned to oral antibiotics.
During the hospital stay, the patient started radiation treatment. The patient remained in stable clinical condition. 
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with complaints of a cough, shortness of breath, and hemoptysis. She had only one single episode of hemoptysis, and it was clearly indicated in the notes that the CT scan of the chest showed no pulmonary embolism, or clear signs of pneumonia or pneumonitis. The patient's symptoms were most likely related to worsening metastatic disease.
The review of the medical records clearly demonstrated that the patient had no evidence of acute respiratory failure. There was no documentation of severe airflow or ventilation abnormalities, overwhelming evidence of infection, or severe pulmonary arterial hypertension.
The bronchoscopy with balloon dilation performed during the hospital stay is an outpatient procedure, including the initiation of radiation therapy, which is usually performed on an ambulatory basis.
Taking into consideration all of this information, there is not overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems- Stroke/CVA
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient is an adult female with prediabetes and asthma who presented to the hospital with right arm numbness and tingling. The patient developed symptoms the day before that came and went several times. On the day of presentation, she entirely lost sensation in the right arm for approximately five minutes and the arm felt clumsy and unable to text on a cell phone. The patient presented to the emergency room where she underwent a computed tomography (CT) scan of the head and computed tomography angiography (CTA) of the Head and neck. These studies were unremarkable. Her vital signs and initial lab values were unremarkable. She was admitted to the hospital for evaluation of stroke. A magnetic resonance imaging (MRI) scan of the brain was performed that showed anabolic appearing stroke in the left parietal lobe. The patient had no known or detected arrhythmia. She underwent an echocardiogram that showed an intra-atrial septal aneurysm and intracardiac shunt with mini bubbles in the left heart and a patent foramen ovale. The patient was treated with aspirin, Plavix, and a statin. She was scheduled with cardiology for patent foramen ovale closure as an outpatient.

The inpatient hospitalization is medically necessary. The patient is a young female with pre-diabetes who developed sensory changes in the right arm. These sensory changes initially waxed and waned and then became fixed. The patient presented to the emergency room and, although initial imaging was negative for an acute process, an MRI of the brain showed in acute embolic stroke in the parietal lobe. Although the deficits were "non-disabling," the patient did have an acute stroke and required inpatient testing and evaluation for causes of a stroke in a young person. The patient had no other risk factors than prediabetes. After thorough testing, the patient was found to have an intra-atrial septal aneurysm and shunt that was likely responsible for the stroke, although a lower extremity Doppler study was negative. Regardless of the stroke symptoms, the work up and evaluation of an ischemic stroke is similar and requires a variety of inpatient testing, nursing, and rehabilitation evaluations. This degree of testing is generally not performed in observation as the patient had continued deficits and ischemia on an MRI of the brain. Additionally, the patient required consultation with various specialists due to the abnormal and causative cardiac findings. While evaluation of transient ischemic attack may be completed in a lower level of care, the evaluation of Stroke is still appropriate for inpatient care, especially in a young patient with no prior risk factors.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Pain Management (Radiofrequency Ablation / Intracept).

The insurer denied: Pain Management (Radiofrequency Ablation / Intracept).  The denial is upheld.

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been recommended. Physical exam shows no neurological deficits. She has failed non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and injections. The procedure was denied as experimental/investigational. This is being appealed.

The proposed treatment is not medically necessary.

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been recommended. Physical exam shows no neurological deficits. She has failed non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and injections.

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (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, typically in situations where conventional and typical options have been exhausted.

However, this patient has not failed or attempted facet interventions/sacroiliac joint injections, which are common causes of axial low back pain.  The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed.  The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives, sacroiliac injections, do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically necessary.

The procedure is a Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized controlled trials (RCT) with five-year results. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (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, typically in situations where conventional and typical options have been exhausted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient is an adult female with medical diagnosis of acute abdominal pain and presented to the Emergency Department (ED) with complaints of (c/o) abdominal pain and fever. Initial evaluation showed temperature of 100.5 degrees Fahrenheit, examination revealed diffuse abdominal tenderness otherwise unremarkable with normal bowel sounds, no rebound. Ultrasound (US) done showed small intraluminal stones, negative Murphy's sign, common bile duct of 3mm (millimeters). There was no pericholecystic fluid and no gallbladder wall thickening. Labs showed minimally elevated alkaline phosphate of 133 with upper limit of normal of 126. The bilirubin was 0.3, white blood cells (WBC) 6.3, alanine transaminase (ALT) and aspartate transaminase (AST) were mildly elevated. The treating provider ordered inpatient admission. 

There was no evidence of acute cholecystitis or other acute abdominal process needing acute inpatient management. 

"Gallstones or cholelithiasis are stones that form in the gallbladder composed of cholesterol, bilirubin, and bile. These stones are asymptomatic in most cases, with stones discovered incidentally. Symptomatic patients present with right upper abdominal pain after eating greasy or spicy food, nausea, vomiting, pain in epigastrium that radiates to the right scapula or mid-back." (Jones, et al., 2022). 

"Approximately twenty percent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty percent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted." (Portincasa, et al., 2019).                                                  

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hemorrhagic ovarian corpus luteum.
Treatment: inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is a female who presented with abdominal pain of 2 days duration. Vitals were stable. The patient has a history of end stage renal disease status/post (s/p) failed renal transplant. Ultrasound on presentation showed a right ovarian hemorrhagic corpus luteum. The patient was admitted for observation and serial hematocrits and possible surgical intervention. The patient's pain improved. Her hematocrit was stable. The patient underwent 2 hour dialysis and was discharged home.

Most patients with ovarian cyst rupture have an uncomplicated course and are candidates for observation. Complicated patients (i.e., hemodynamic instability, large or ongoing blood loss, signs of an infection process, findings suggestive of malignancy) may require inpatient management and/or surgery.

Patients with hemodynamic instability require immediate surgical management. For most patients with a ruptured ovarian cyst who are hemodynamically stable but have significant hemoperitoneum or concern of ongoing blood loss, hospitalization with close observation. Close observation includes frequent vital signs, serial hemoglobin/hematocrit testing, fluid replacement, and repeat pelvic ultrasound, if needed. Surgery is required if ongoing hemorrhage needs to be controlled and/or if the patient's clinical condition is unstable. 

This is a sick patient who presented with a very low hematocrit. Admission for close observation and possible surgical intervention was medically necessary. 

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure-Intraosseous Basivertebral Nerve Ablation
The insurer denied: Intracept Procedure-Intraosseous Basivertebral Nerve Ablation
The denial is upheld

The patient is an adult male with a history of chronic low back pain. His pain has not responded to epidural steroid injections, home exercise, medications such as NSAIDs (nonsteroidal anti-inflammatory drugs) and Prednisone, and physical therapy. His physical exam was unremarkable. An Intracept procedure has been recommended. The procedure was denied coverage by the health plan as experimental/investigational. This was appealed.

The health plan should not cover the Intracept procedure.
The patient is an adult male with a history of chronic low back pain. His pain has not responded to epidural steroid injections and physical therapy. His physical exam was unremarkable. An Intracept procedure has been recommended. The procedure was denied coverage by the health plan as experimental/investigational. This denial is being appealed.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (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 used in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion. However, the patient has not failed facet joint interventions or sacroiliac (SI) joint interventions, which are common causes of axial low back pain.

Therefore, while the Intracept procedure is a reasonable option for recalcitrant low back pain that has failed all conservative treatment in the setting of vertebrogenic back, it should be employed after all conventional and evidence proven alternatives have failed. Given this is not the case, the requested procedure is not medical appropriate for the patient.