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

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

The patient is a woman who presented to the emergency department (ED) with 3 days of exertional chest pain. She stated that the chest pain was substernal, radiated to the back, and worsened with exertion. The patient had a tooth pulled approximately 7 days earlier and was started on azithromycin. She had "pre-diabetes" but was taking metformin. Physical examination was unremarkable. Troponin x2 was normal. A Chest computed tomography (CT) showed no dissection. An electrocardiogram (ECG) showed no definite ischemic changes. The patient was admitted.

The inpatient admission was not medically necessary for this patient.
The patient had chest pain, possibly related to an acute coronary syndrome. It was reasonable to rule out myocardial infarction (MI) and perform the diagnostic tests. However, the initial aspect of the admission could have been performed at a lower level of care. Once MI was ruled out, the stress test and echocardiogram could have been performed at a lower level or as an outpatient. A full inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Humerus fracture.
Treatment:  Inpatient stay.

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

The patient is a girl who fell and sustained a left Type 3 supracondylar humerus fracture. She was admitted to the hospital and underwent closed reduction and percutaneous pinning of the fracture under general anesthesia. She was neurovascularly intact at the time of admission and had frequent checks of her neurovascular status throughout her hospital stay.

The inpatient hospital admission was medically necessary. A Type 3 supracondylar humerus fracture is a severe injury that may be associated with a number of complications, including ischemia and compartment syndrome. It is essential that these patients be closely monitored for evidence of change in their neurovascular status, and for signs of impending compartment syndrome. It may be necessary to respond urgently if these finding are present. The typical treatment consists of closed or open reduction under general anesthesia, with internal fixation, as was done in this case. The intensity of services required justifies inpatient hospital admission, which should be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain and history of lumbar spine surgeries.

Treatment: 28 hours/week, consumer directed personal assistance services (CDPAS).

The insurer denied coverage for 28 hours/week, CDPAS.

The denial is upheld.

This is an adult with chronic back pain and history of lumbar spine surgeries. The insurer approved 19.25 hours/week CDPAS and the patient is requesting 28 hours/week, which is currently under review.  

According to the Uniform Assessment System (UAS) report reviewed, the patient's cognitive skills are described as "Independent-Decisions consistent, reasonable and safe." She requires only limited assistance for bathing and lower body dressing. She is otherwise at the supervision to independent level for personal hygiene, upper body dressing, bed mobility, ambulation, eating and toilet transfer/use. The patient is infrequently incontinent of bladder and continent of bowel. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS 28 hours/week; particularly since much of her activities of daily living (ADL) status is primarily at the supervision or independent level. CDPAS for companion care or safety supervision without the direct provision of ADL tasks is not a covered service. Based on the enclosed documents reviewed, the patient's health and safety is appropriately provided and maintained by the currently approved CDPAS 19.25 hours/week.  

From a physical medicine and rehabilitation perspective, the requested increase CDPAS 28 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 28 hours/week, CDPAS services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right shoulder pain.

Treatment: continuing Physical Therapy.

The insurer denied coverage for continuing Physical Therapy.

The denial is upheld.

 
This is a teenager with complaints of right shoulder pain secondary to falling off a horse. There were no focal neurological deficits and right shoulder magnetic resonance imaging (MRI) scan was normal. Treatment included physical therapy that began several months ago. Ongoing physical therapy (PT) treatment is under review.  

There were no physical therapy treatment notes made available for review providing objective clinical information to support the medical necessity for the dates of service under review. Physical therapy treatment notes must be provided in order to establish the medical necessity of a structured out-patient physical therapy treatment program. There is no documentation of a specific diagnosis or detailed clinical assessment. After more than 6 months of treatment and nearly 50 therapy sessions, evidence of significant progress should be documented in order to support continued treatment. The provision of extensive physical therapy, without documented functional improvement is essentially maintenance treatment and therefore not medically necessary. In addition, after more than 6 months of physical therapy, the patient should be independent with a home exercise program.  

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the enclosed clinical information available for review, ongoing PT treatment was 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 ongoing physical therapy (PT) treatment is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: respiratory distress
Treatment: inpatient stay
The insurer denied an inpatient stay. 
The health plan's determination is overturned.

This is the case of a male with congenital hydrocephalus and asthma who presented to the emergency department (ED) with cough, wheeze, and difficulty breathing. Symptoms were not responsive to home albuterol use. Past medical history is significant for ventriculoperitoneal (VP) shunt placement at 3 months old and 1 prior hospitalization for asthma.
ED vitals were T (temperature) 37.1oC, heart rate (HR) 114, respiratory rate (RR) 40, and O2 (oxygen) saturation 98% on room air. The exam was notable for acute distress with tachypnea, prolonged expiratory phase, and retractions. Wheezing was heard on auscultation.

The requested inpatient hospitalization is medically necessary for this patient. This child with asthma and prior hospitalization presented to the emergency department (ED) with acute respiratory distress that was unresponsive to home albuterol. In the ED, the patient received typical acute asthma protocol with oral steroids and Duoneb x 3. He then received additional therapy with intravenous fluids (IVF) and magnesium sulfate due to inadequate response and continued respiratory distress. Per medical records provided, the patient still required frequent albuterol at the time of admission. Based on expert guidelines, an inpatient admission appropriate as children cannot always be assessed in ways similar to adults.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is an adult female with dementia. She was admitted due to combative behavior. Upon arrival to the ER (emergency room), the patient required IV (intravenous) Versed, Ativan and 1:1 (one to one) monitoring. She saw psychiatry, neurology and PMR (physical medicine and rehabilitation). She 
was determined to have severe dementia with behavioral problems. It was also noted she became aphasic with rapid speech declined. She was recommended to be placed in a dementia unit. Continued aggression required continued observation, IV (intravenous) Haldol and restraints.

The Inpatient Hospital Admission was medically necessary.

The patient had severe dementia and would have been a threat to herself and others if she were to have been released. She required admission to dementia unit. Furthermore, she required IV (intravenous) Haldol as well as restraints which could not be done in the outpatient seeing. Furthermore, patient safety is an issue while being admitted despite observation, which would 
indicate that outpatient management of condition would be dangerous and would lead to problems.

Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Injury to her low back, coccyx, left hip, and left heel due to being struck by a sports utility vehicle.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This adult female presented after being struck by a sports utility vehicle (SUV) resulting in injury to her low back, coccyx, left hip, and left heel. This occurred in Tampa, Florida. The patient signed out of the hospital against medical advice (AMA) to catch a flight back to Rochester. She reports wheelchair transportation during the flight and having to crawl at home due to ankle pain. The patient's vital signs were stable. Her exam was remarkable for pain on dorsum and medial ankle. There was no fracture on x-ray. The patient was admitted for pain control with intravenous Toradol, Tylenol and Lidoderm. The patient continued to complain of pain and required assistance with mobility. The pain started to improve on the fourth day. The patient continued to receive intravenous Toradol. She was given Norco on the fifth day. The patient was discharged on the following day after showing improved ambulation and pain control.

The proposed treatment was not medically necessary.

This patient was admitted for pain control after trauma resulted in contusions and pain. She was hemodynamically stable. The patient did not have fractures. Her exam was remarkable for limited mobility due to pain. She was able to tolerate oral intake (PO). The patient had not failed a lesser level of care. Inpatient admission was not medically necessary for this patient who was able to tolerate oral intake and be managed with oral pain medications. In addition, physical therapy did not require an acute inpatient level of care. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroid eye disease
Treatment: Tepezza
The insurer denied coverage for Tepezza.
The denial is overturned.

 
The patient has a history of thyroid eye disease. In the clinic note the patient was noted to have bilateral lid retraction, exophthalmos, and 1 plus (+) injection over rectus muscles. The patient was noted to be in the active inflammatory stage of thyroid eye disease.

In a letter, the physician states that the patient was started on Tepezza infusion the previous year and finished infusions six months later. She was noted to have done well for six months but has noticed a recurrence of her symptoms for the past 3 months. On exam, she was noted to have exophthalmos, lid retraction and limitation of motility in all directions of gaze.

In a letter, the request for Tepezza was denied because the request exceeded the maximum recommended treatment duration of 8 total lifetime infusions for the diagnosis of thyroid eye disease based on the United States Food and Drug Administration (FDA) product labeling.

The patient's thyroid eye disease continues to progress, with worsening swelling, eye bulging and double vision. She has bilateral upper and lower lid retraction and limited eye movements in all directions of gaze. The patient has had a reactivation of her thyroid eye disease and requests a second round of Tepezza.

The patient has a recurrence of active thyroid eye disease, and a recent study has shown that some patients may require an additional course of Tepezza. (3) Repeat use has also been described for recurrent disease in a recently published consensus. (4)

The patient has evidence of active thyroid disease, as indicated by the patient's symptoms and exam findings of proptosis, eyelid retraction, and diplopia. Teprotumumab is an FDA approved drug for the treatment of the patient's condition and has been shown to result in better outcomes in terms of reducing proptosis, improving clinical activity score, diplopia and quality of life. (2)

Tepezza is used in accordance with accepted standards of good medical practice and is clinically appropriate for the patient's condition.

Tepezza is considered medically necessary for this patient. Teprotumumab (Tepezza) is an FDA-approved drug for the treatment of the patient's condition and has been shown to result in better outcomes with respect to proptosis, clinical activity score, diplopia and quality life among patients with active thyroid eye disease. (2)

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for Tepezza services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is upheld.
 

This is a toddler with respiratory symptoms of cough and fast breathing who presented to the Emergency Department (ED). In the ED, the patient was noted to not be in distress. The patient was seen in another local ED 1 day earlier and discharged with a high dose of amoxicillin. In this ED the patient had mild tachypnea at 28 breaths per minute, and no wheeze. The temperature was 102.1 degrees Fahrenheit. The oxygen saturation was 97 percent (%) on room air. No hemodynamic instability was noted. The patient's perfusion was adequate. The chest x-ray was normal. The patient was treated with nebulization and steroids. The clinical status improved. The patient was discharged with scheduled nebulization and steroids and close pediatrics follow up.

There was no persistent hypoxia and no need for continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC). There was only a minimal need for oxygen. There was no need for pressors nor multiple boluses. There were no abnormal labs that persisted. No arterial blood gas (ABG) was done because there was no hypoventilation nor any hypercarbia. The clinical status was not serious enough to give intravenous (IV) steroids. Decadron was given which is slow acting. There was no severe dehydration as evidenced by normal physical exam and labs. There was no second line treatment such as continuous albuterol nor epinephrine nor terbutaline. If one were to take the Preschool Respiratory Assessment Measure (PRAM) score to assess the pediatric asthma, it would be in the category of mild asthma. The reason for asthma exacerbation is viral illness. If one were to take the Pediatric Early Warning Systems (PEWS) score, it would also indicate an expectant and stable course in the hospital. This child with mild to moderate asthma exacerbation from a viral illness could have been treated in observational status.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept procedure.
The health plan's determination is upheld.

The patient is a male with a past medical history (PMH) of lower back pain for the past 22 years who presented with ongoing lower back pain. He had a magnetic resonance imaging (MRI) which was notable for disc bulge at lumbar (L) 4-5 with ligamentum flavum hypertrophy and facet hypertrophy with moderate neuroforaminal and minimal central stenosis at this level. Additionally, at the L5-sacral (S) 1 level, mild degenerative endplate edema was noted.

The patient had an evaluation and it was noted that he has received treatment with over-the-counter (OTC) medication, prescription (rx) medication, physical therapy (PT), chiropractic and facet radiofrequency ablation (RFA) in the past. The patient's pain was rated a 6-7 out of 10. His exam is notable for pain with facet loading. The initial plan was to perform a repeat L3-5 lumbar facet medial RFA on each side. At this visit, the Intracept procedure was also discussed.

There is insufficient evidence to support whether the Intracept procedure will be more beneficial than standard treatment in this case. I looked for and could not find evidence of clinical records outlining his responses to less invasive treatments including medication trials, physical therapy and prior interventional trials. It appears a component of his pain may be facetogenic in origin and the initial plan was to perform bilateral lumbar RFA at first. I looked for and could not find the outcome of medial branch block (MBB)/RFA following the initial visit to assist in determining the need for further interventional procedures.

The request is for an Intracept procedure which is being requested for vertebrogenic pain. While the patient has had evidence of pain for greater than (>) 6 months and an MRI demonstrating modic changes within the L3-S1 vertebral bodies (at L5-S1 he had MRI evidence of "mild degenerative endplate edema slightly more conspicuous than the prior exam"), I looked for and could not find clinical evidence that he has failed treatment for over 6 months. I looked for and could not find clinical information on outcomes of RFA and clinical documentation supporting that his primary pain is vertebrogenic pain in comparison to facetogenic mediated pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept procedure.
The health plan's determination is upheld.

The patient is a male who was diagnosed with low back pain. There is a letter of appeal from the treating provider stating that they disagree with the denial of the Intracept procedure as this is an innovative procedure to address chronic low back pain identified by Modic changes. It also fulfills a treatment gap for patients with chronic low back pain. The provider states that the patient has had low back pain for more than 22 years and has tried multiple treatments including chiropractic care, heat, ice, injections, medication management, physical therapy, and radiofrequency ablations without sustained relief. The patient's pain ranges from 6 to 7 out of 10. The provider states that the patient had a magnetic resonance imaging (MRI) that demonstrated degenerative endplate changes at disc spaces lumbar (L) 4, L5, and sacral (S) 1. Therefore, his chronic back pain is coming from the vertebrogenic changes at L4, L5 and S1.

The MRI of the patient's lumbar spine showed a slightly more conspicuous degenerative endplate edema signal at L5 to S1. There is a similar mild edema signal at the facets at L4 to L5. The L4 to L5 disc bulge at the center contributes to mild spinal canal stenosis and moderate bilateral foraminal narrowing, similar to the prior examination. Other lesser degenerative changes were similar to the prior examination.

The proposed health service and treatment for the Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition or disease. The patient is noted to have a history of chronic back pain that the provider believes is coming from Modic changes and recommended the Intracept System (intra-osseous basivertebral nerve ablation). Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Despite promising early reports, further trials with longer term outcomes and less risk of bias are required." There continues to be a lack of quality studies evaluating the long term risks and benefits when compared to other standard means of treatment and further large high-quality studies are needed. This treatment is not currently considered the standard of care in the general medical community. There is no evidence to suggest this treatment would be more beneficial than standard treatment options for the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High blood sugar
Treatment: Inpatient hospital stay
The health plan denied the requested inpatient hospital stay as not medically necessary.
The health plan's determination is upheld.

This is a male with obesity, fatty liver, and prediabetes who presented to the Emergency Department after being referred by his primary care provider for a 60-pound weight loss over 2 months. The patient was having polydipsia and polyuria. His vital signs were a blood pressure (BP) of 131/85 millimeters of mercury (mmHg), with a heart rate of 68 beats per minute (bpm), a temperature of 97.4 degrees Fahrenheit, a respiratory rate of 18/minute, and an oxygen saturation of 97% (percent). He was alert and oriented on exam. Labs included a glucose of 481, a sodium of 129, a urine glucose greater than or equal to 1000, a beta-hydroxybutyrate of 2.4, and a hemoglobin A1C greater than 14%. The patient was given Magnesium for a magnesium level of 1.6. He was given intravenous fluids and was started on Metformin and Sitagliptin. The patient was discharged on Metformin and Sitagliptin.

At issue is the medical necessity for the inpatient hospital stay. I uphold, in whole, the health plan's determination of medical necessity. The requested inpatient hospital stay was not medically necessary.

This patient presented with new onset of type 2 diabetes. He had hyperglycemia, which improved with hydration and oral glucose lowering medications. He had a normal potential of hydrogen (pH) of 7.34 and he did not meet criteria for diabetic ketoacidosis. He was awake and alert and did not meet criteria for hyperglycemic hyperosmolar state. The patient was hemodynamically stable. He did not have evidence of infection or other acute condition requiring an inpatient hospital stay. The records do not support that he tried and failed a lower level of care. Therefore, the requested inpatient hospital stay was not medically necessary.