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

Diagnosis: Left Knee Osteoarthritis
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

This is an adult with a history of seizure disorder, traumatic subdural hematoma, stroke with right hemiplegia, gastroesophageal reflux disease (GERD), and benign prostatic hypertrophy (BPH). The patient presented to the hospital for a scheduled total left knee arthroplasty. The patient tolerated the procedure well with no issues. Pain was well controlled after surgery. The patient worked well with physical therapy and occupational therapy (PT & OT). The patient was discharged.  

The medical records demonstrate the patient has a unique clinical condition to warrant admission and length of stay. He had a previous stroke with other underlying medical conditions. He was at increased risk for post-surgical complications. 

He required approximately 4 hours of anesthesia with adductor block. His pain was tolerable and vital signs stable but, the facts were he was only able to be mobilized to stand with moderate assist. He was able to initially walk 3 feet with a special platform crutch. He had a problem with the wound. He was reported to have had 600 milliliters (ml) of drainage from the Hemovac. This is abnormally high. The medical record stated, "plan to monitor drainage and labs". His Hemovac was not removed until 2 days after his surgery. Discharge with ongoing drainage is not recommended. 

Based upon problems with ambulation and increased blood loss to require maintenance of drain, ambulatory type of admission would not be applicable. Inpatient stay would be consistent with current standards of practice. 

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

The inpatient admission is considered medically necessary for this patient.

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

Diagnosis: Moderately impaired cognition.
Treatment: Consumer Directed Personal Assistance - 24 Hours per Day, Seven Days per Week (Split Shift).
The insurer denied: Consumer Directed Personal Assistance - 24 Hours per Day, Seven Days per Week (Split Shift).  The denial is upheld.

The patient is an elderly male.  Uniform Assessment System - New York, assessment states the reason for evaluation is a decline in the patient's condition.  The patient is in a nursing home.  His cognition is moderately impaired; the patient is alert and oriented times one.  He is forgetful and does not self-direct.  He is total dependence for activities of daily living with maximum to extensive assistance.  His condition has declined.  The patient is forgetful.  He requires extensive assistance with dressing the lower body. The patient is frequently incontinent of the bladder.  The patient requires total assistance with medication management and administration of medications.

The request is for consumer directed personal assistance 24 hours per day, seven days per week (split shift).

The proposed treatment is not medically necessary.

The patient's condition has declined significantly; the patient has skilled nursing care needs that exceed the personal care an aide can provide including medication administration.  Personal care services are not enough to provide the patient with the care he needs.  The patient requires safety supervision.  The patient's medical condition has significantly changed and declined, and care cannot be established at home safely.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea and diarrhea.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is overturned.

The patient is an adult female, with two total pregnancies including the current one, one term delivery, and one living child (G2P1001), who presented to the hospital at 17 weeks two days gestation with initial complaints of nausea and diarrhea.  Due to the presence of someone in the home with similar symptoms, it was initially presumed that she had gastroenteritis.  She also complained of possible leaking some fluid per vagina.  Subsequently, during her treatment in the emergency room, she developed emesis and was unable to tolerate oral intake despite prolonged observation in the emergency room and multiple parenteral doses of Zofran, Reglan, and Pepcid.  

Due to her intractable nausea and vomiting and ketonuria, the patient was admitted for supportive care.  Ruptured membranes was ruled out with Amnisure and ultrasound was consistent with dates and was documenting normal amniotic fluid volume.  The patient received ongoing supportive treatment and on hospital day #3 was tolerating a regular diet, the gastrointestinal (GI) symptoms had resolved, and she had residual borderline hypokalemia, which was treated with replacement.  She was discharged home.  

The health plan contends that the admission was not medically necessary due to absence of severe issues such as severe fluid or heavy blood loss, high fever or severe infection, low blood pressure, severe pain or vomiting that did not respond to early treatment and cites Milliman Care Guideline (MCG) for Gastroenteritis (ORG: M-170) and Obstetric and Gynecologic Disease (GRG: MG-OBD).  The facility contends that the hospitalization was medically necessary due to presenting factors, significant abnormal risk factors, and the medically necessary treatment and cites Milliman 25th Edition Guidelines Gastroenteritis (M-170-RRG) dehydration that is severe or persistent and failure to maintain oral hydration that persists after observation care, and GRG: CG-GAC (ISC GRG) Inpatient treatment and monitoring, intravenous hydration, intravenous antiemetics, strict input (I) and output (O) monitoring, serial lab studies, and obstetric follow up.

The proposed inpatient admission was medically necessary.

Although at the time of initial presentation the major complaints were nausea and diarrhea, during observation the patient developed intractable emesis that did not respond to three rounds of parenteral antiemetics, and she could not keep oral fluids down as well as exhibiting persistent ketonuria.  Both obstetrics and gynecology (OB/Gyn) guidelines (the American College of Obstetrics and Gynecology [ACOG] practice bulletin - cited) and Internal Medicine texts (Yamada's Gastroenterology - cited) state that hospitalization is indicated for intractable vomiting after failure of initial outpatient treatment.  Therefore, standard guidelines for clinical care state that hospitalization was indicated for this patient, and, therefore, the treatment was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, stroke and dementia
Treatment: Home care / personal care HHC (home health care) - level 2 personal care services (PCS), per 15 minutes increase to 84 hours per week
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week
The denial is upheld

This is an elderly adult with chronic medical problems including coronary artery disease, stroke and dementia.  She lives with her daughter who is the care giver.  The insurer approved at home care / personal care HHC - level 2 PCS, per 15 minutes 40 hours/week.   The request is an increase PCS to 84 hours/week.

In the Uniform Assessment System (UAS) report, the patient is described as "Minimally impaired."  She requires extensive assistance for bathing, and lower body dressing.  However, only limited assistance is needed for personal hygiene, upper body dressing, ambulation (with a rolling walker) and toilet transfer/use.  She is frequently bladder incontinent and continent of bowel.  She requires supervision for bed mobility and eating.  Her functional ability is much the same as documented in prior UAS report.  The patient's condition and functional needs are not at a level, unpredictable or significantly declining as to require the requested PCS 84 hours/week.  This physician would agree the patient may require additional monitoring.  However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided.  Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the current PCS services, 40 hours/week.  

From a physical medicine and rehabilitation perspective, the requested PCS increase to 84 hours per week is not medically necessary.  

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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion
Treatment: Braces
The insurer denied braces.
The health plan's determination is upheld.

The patient in question is a male with a Class I occlusion with appropriate overbite and overjet. He has maxillary spacing and mild mandibular crowding. He is treatment planned for 24 months of braces to correct his malocclusion. This is the subject under review.

Braces are not medically necessary. While the patient has maxillary spaces, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Borderline anemia. 
Treatment: inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with medical history of deep venous thrombosis and pulmonary embolism on warfarin, Ulcerative Colitis, multiple sclerosis on chronic steroids, diabetes mellitus type II, and seizure disorder. She presented to the emergency department with diffuse bruising of the skin and generalized pain. 

The inpatient hospital stay was not medically necessary. In this case, the patient presented with bruising and pain, as well as borderline anemia, in the setting of very elevated international normalized ratio while on warfarin for the treatment of deep venous thrombosis and pulmonary embolism. She was appropriately treated with vitamin K and suspension of warfarin therapy. She had bruising, but did not have any other complications, such as visible bleeding or hemodynamic instability. There was no evidence of active Ulcerative Colitis. She chose to leave the emergency department. During her short stay, the care provided, including monitoring, labs, and vitamin K therapy, could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a patient with a past medical history (PMH) of a small bowel obstruction (SBO) who was admitted with complaints of (c/o) a 24-hour history of abdominal pain associated with emesis. His vital signs were unremarkable. The physical exam was notable for abdominal tenderness to palpation (TTP), positive (+) guarding. Lab work was unremarkable. A computed tomography (CT) scan of the abdomen/pelvis showed findings consistent with (c/w) SBO involving the distal ileum. The patient was diagnosed with adhesive SBO and treated with non-operatively with nothing by mouth (NPO), intravenous fluids (IVF), nasogastric (NG) tube, surgery evaluation, and serial abdominal exams. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was medically necessary at an acute inpatient level of care.

This patient presented to the emergency department with complaints of abdominal pain associated with nausea and vomiting. He was found to have a small bowel obstruction on radiography evaluation, and was admitted for urgent surgical consultation and close observation. All patients with suspected/confirmed intestinal obstruction should be admitted with early surgical consultation, especially in this patient with a prior history of SBO. Such patients require hospital admission for resuscitation, decompression, serial abdominal examination, and possibly operative therapy. Overall, this patient's clinical presentation, and clinical concern for acute surgical abdomen, required the patient to have an acute inpatient level of care for safe treatment and monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Croup. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This is a male child with three days of fever, headache and a sore throat. He developed a croupy cough one day prior to the admission. On the day of admission, he was noted to have difficulty breathing and was taken to the emergency room (ER) by emergency medical services (EMS) for additional treatment. He was born at term and was hospitalized for five days with a diagnosis of pneumonia. There was a hospitalization in the past for a cough. There is a family history of asthma. 

In the ER, the child was noted to be in respiratory distress with increased work of breathing. He had a barking cough. On physical examination he was described as obese and was noted to have wheezing on examination of his lungs. He required three additional inhalation treatments in the ER with racemic epinephrine for recurrence of the stridor and difficulty breathing. Because he had failed to improve with treatment in the ER the decision was made to admit him to the hospital for ongoing treatment with a with a diagnosis of croup. 

The patient was treated appropriately in the emergency room for an acute illness with croup. He had been treated with intravenous (IV) steroids, albuterol and 4 doses of racemic epinephrine over a 6-hour period of observation in the ER and he continued to have stridor and wheezing. The medical record does support the need for admission to the hospital for observation and continued treatment. The admission was consistent with the standard of care for a child in respiratory distress with recurrent stridor which did not improve with 4 doses of racemic epinephrine and steroids in the ER. 

Based on the above, the insurer's denial must be reversed. 

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

The medical necessity for inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Submandibular swelling and pain
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

The patient presented the emergency department (ED) with submandibular swelling and pain. The patient had an oral/maxillofacial surgery consult. A computerized tomography (CT) scan was completed, and based on findings, the patient was admitted for further management, including intravenous (IV) antibiotics. The patient had an incision and drainage (I&D) of an abscess around a tooth and some teeth were extracted the day after admission. The patient was discharged two days later.

There were attempts made to control the symptoms of discomfort prior to taking the patient to the operating room (OR). A 2 x 2-centimeter (cm) abscess was seen and was refractory to IV antibiotics. Surgical drainage with dental extraction of the inciting teeth was appropriate. This cannot be done without going to the OR under sedation and having a stay after to determine stability, culture results, and improvement of symptoms. The literature supports acute intervention to avoid lethal complications.

According to Sanders et al (2022), "Left untreated, these infections can be not only extremely painful but also pose a significant risk of descending into the deep neck space or ascending to intracranial sinuses."

According to Bertossi et al (2017), "The vast majority of dental abscesses respond to antibiotic treatment, however, in some patient's surgical management of the infection may be indicated."

According to Cramer et al (2016), "In adults, delay in surgical drainage of deep neck abscess is associated with increased mortality and morbidity (M&M)."

The patient was not able to improve with conservative, non-surgical management, such as pain control and IV antibiotics. A procedure in the operating room was necessary for patient comfort and ultimate improvement. Dental extraction and abscess drainage can be painful, and a post-operative stay was merited to ensure improvement of symptoms and patient stability. The transition to oral antibiotics after the procedure and discharge was medically sound judgment.

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 inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Nerve Ablation (64628x1, 64629x1)
The insurer denied: Intraosseous Nerve Ablation (64628x1, 64629x1)
The denial is upheld

The patient is an adult female with low back and lower extremity pain.  Her leg pain was relieved 80% by a transforaminal epidural steroid injection. Current medications include cyclobenzaprine and diclofenac.  Magnetic resonance image (MRI) of the lumbar spine is significant for a prior right L4-5 (lumbar four/lumbar five) laminectomy, multilevel spondylosis bilateral foraminal stenosis, and an annular tear at L3-4 (lumbar three/lumbar four).  The request for Intracept at L3-4 (lumbar three/lumbar four), L4-5 (lumbar four/lumbar five) was denied as experimental/investigational.

The health plan should not cover the proposed treatment.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.   

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable.  There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such the health plan should not cover the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Nerve Ablation (64628x1, 64629x1)
The insurer denied: Intraosseous Nerve Ablation (64628x1, 64629x1)
The denial is upheld

The patient is an adult female with chronic low back pain with radicular pain into the left lower extremity past the knee secondary to a combination of a lumbosacral radiculopathy and lumbar spondylosis.  The patient's magnetic resonance imaging of the lumbar spine showed: Modic changes in L4/L5 (lumbar four/lumbar five), multilevel spondylosis most prominent at the L4/L5 (lumbar four/lumbar five) level, and multilevel intervertebral disc herniation causing mild to moderate neuroforaminal stenosis.  Also, the patient responded very well to a lumbar epidural steroid injection (about 80% pain relief for six months) and a right lumbar radiofrequency ablation (80% pain relief).  The pain is an eight out of ten (8/10) that has persisted for over ten months, and it has not responded to over 12 weeks of conservative management to include physical therapy and medication management with non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants.  The treating physician recommended the Intracept procedure, but it was declined by the health plan.

The health plan should not cover the proposed treatment for this patient.

Although the medical literature shows that the Intracept procedure is effective and safe for individuals who have greater than six months of axial low back pain that has not responded to conservative management with magnetic resonance image (MRI) findings of Modic changes between vertebral levels L3 - S1 (lumbar three to sacral one), it is not indicated if other medical diagnoses can explain the cause of the patient's pain.  
In this case, the patient has a combination of lumbar spondylosis and lumbar radiculopathy that are causing the majority of her pain based on the fact that a lumbar epidural steroid injection provided 80% pain relief of her left lower extremity radicular pain for six months and a bilateral lumbar radiofrequency ablation provided 80% pain relief.  In addition, the report of the magnetic resonance image (MRI) of the lumbar spine only showed Modic changes at the L4/L5 (lumbar four/lumbar five) level, but the request is for the Intracept procedure at the L3/L4  (lumbar three/lumbar four) and L4/L5 (lumbar four/lumbar five) levels.