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

Diagnosis: Fall
Treatment: Inpatient Hospital Stay

The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a medical history of end-stage renal disease (ESRD), hypertension (HTN), human immunodeficiency virus (HIV), and deep vein thrombosis (DVT) on oral anticoagulation (OAC). The patient was admitted to the hospital with complaints of right hip pain after falling off a bicycle. The patient also reported chest pain (CP) and shortness of breath (SOB) during dialysis but noted these complaints were not new. The patient's vital signs and lab work were unremarkable. The physical exam showed a limited range of motion (ROM) in the right lower extremity due to pain, and the patient had normal strength. Imaging studies, a computed tomography (CT) scan of the bony pelvis showed a minimally displaced traumatic fracture on the right superior public ramus. An electrocardiogram (EKG) revealed a new T-wave in 6 volts (V6). The patient was diagnosed with a minimally displaced traumatic fracture on the right superior pubic ramus. Diagnostic imaging work-up and non-surgical treatment modalities were administered, including physical therapy, orthopedic consultation, and pain control. The patient was discharged against medical advice (AMA) in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient's diagnostic imaging workup showed that the patient only had a minimally displaced traumatic fracture on the right superior public ramus. An orthopedic consultant evaluated the patient and did not recommend surgical intervention but did suggest additional imaging and anticipated admission for physical therapy (PT). Observation is an ideal setting for care coordination and discharge planning and an opportunity for assessment by a physician, physical therapist, social worker, and care manager for these types of patients. Patients in observation receive focused interventions in mobility, gait training, and functional status improvements. Overall, this patient had neither severe acute pathology nor the need for acute surgical intervention. The diagnostic imaging work-up and non-surgical treatment modalities that were provided could have been safely and appropriately administered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lower extremity cellulitis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient is an adult with a past medical history significant for diabetes mellitus (DM), hyperlipidemia (HLD), asthma, and inguinal hernia who presented to the emergency department (ED) with complaints of right lower leg rash and erythema.

Vital signs on presentation included: Temperature 36.9 Celsius, blood pressure 120/69, pulse 96, respiratory rate 18, oxygen (O2) saturation 93% on room air. Laboratory results included the following: White blood cell count (WBC) - 8.34k, hemoglobin (Hgb) -14.2, hematocrit (Hct) - 46.9, creatinine - 1.25, glucose - 155, C-reactive protein (CRP) - 1.48. 

The patient was started empirically on intravenous (IV) antibiotics (Vancomycin and Cefepime) for right lower extremity cellulitis. Infectious Diseases (ID) consulted and recommended one dose of Solumedrol for likely allergic drug reaction to outpatient antibiotics. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue outpatient management.

According to documentation, the patient presented with right lower leg rash. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. The patient had no evidence of a disseminated infection, and no surgical intervention was required. Infectious Diseases recommended Solumedrol for likely allergic drug reaction to outpatient antibiotics. Based on above findings, the patient met criteria for observation level of management.

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Exertional chest pain.
Treatment:  Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

This adult male patient was hospitalized for an elective procedure. His past medical history is remarkable for former smoking, hypertension, depression and nasal polyps. The patient was being evaluated for exertional chest pain and subsequently had an abnormal nuclear stress test showing inferior ischemia. 

The patient's vital signs were blood pressure (BP) 145/74, heart rate (HR) 58, respirations (R) 15, temperature (T) 97.3, and oxygen 97 percent. Electrocardiogram (EKG) showed sinus bradycardia. Cardiac catheterization showed severe 2 vessel coronary artery disease (CAD) involving the left anterior descending (LAD) and left circumflex (LCx). The patient then underwent successful complex percutaneous coronary intervention (PCI) to both vessels on the same day. There were no procedural complications. He was observed overnight and discharged following day.

The requested health service was not medically necessary.

The patient underwent planned left heart catheterization (LHC) followed by successful and uncomplicated percutaneous coronary intervention with stenting of the left anterior descending (LAD) and left circumflex on the same day. The information provided does not support the medical necessity for admission after his successful and uncomplicated coronary intervention. 

Percutaneous coronary intervention procedures are routinely performed in the ambulatory setting with observation. There is no documentation of unstable medical conditions like acute coronary syndrome (ACS) / acute myocardial infarction (AMI), cerebral vascular accident (CVA), contrast nephropathy, acutely decompensated congestive heart failure (CHF), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. Therefore, based on the submitted information and the current published medical literature, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic knee pain

Treatment: peripheral nerve stimulator (PNS), code 64555 x 2 percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

The insurer denied coverage for peripheral nerve stimulator (PNS), code 64555 x 2 percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

The denial is upheld. 


This patient has Complex Regional Pain Syndrome (CRPS) after having had knee arthroscopy.  The patient has had physical therapy and chiropractic. The patient is taking Gabapentin.  There is no documentation of other interventions such as sympathetic nerve block, Ketamine infusions, Spinal cord stimulation, or Dorsal Root Ganglion stimulation. 

Both ECRI (1) and Hayes inc. (2) conducted systematic reviews of the peripheral nerve stimulator (PNS) Sprint system and found it was deemed effective for specific peripheral neuropathies.  It has not been established as an effective therapy for Complex Regional Pain Syndrome type 1 or 2.

The patient has several evidence-based therapies available and there are no comparative studies suggesting that this technology is in any way superior.  Specifically, there is no documentation of Ketamine infusions, spinal cord stimulator (SCS) trial or Dorsal Root Ganglion trials.

Long term effectiveness and complication rates are not well established for Peripheral Nerve Stimulation, and it is not certain that the requested procedure has the same or lower risks than standard therapies.

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 peripheral nerve stimulator (PNS), code 64555 x 2 percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: urinary retention
Treatment: implantation of a neurostimulator device
The insurer denied implantation of a neurostimulator device
The health plan's determination is overturned. 

The patient is a female with a history of non-obstructive urinary retention who has been unable to tolerate intermittent catheterization. She has recurrent urinary tract infections and not able to empty her bladder. Documentation states the urinary problems have been there for 2 years. She has tried change of diet, acetaminophen, activity modification, adequate fluid intake, alpha 1 blockers, an nonsteroidal anti-inflammatory drug (NSAID), an opioid, antibiotics, anti-fungal pills, caffeine restriction, cranberry juice, decreased fluid intake, exercise, herbal medicines, increased fluid intake, laxatives, medications, muscle relaxant, nutritionist consultation, oral antibiotic, pelvic physical therapy, phenazopyridine, stool softener, tamsulosin. There is no documentation of a significant disability.

The implantation of a neurostimulator device) is medically necessary for this patient. The patient has had significant symptoms related to her non-obstructive urinary retention for over 2 years. She has tried many conservative therapies which have not successfully managed her condition. She does not tolerate intermittent catheterization. Per the International Continence Society Best Practice Statement on Sacral Neuromodation, sacral neuromodulation would be indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular Dementia with Behavioral Disturbance; History of Cerebrovascular Accident; Incontinence
Treatment: Home health care
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week
The health plan's determination is overturned.

This is a male patient with a history of dementia, stroke, coronary artery disease, hypertension, diabetes mellitus type 2, hyperlipidemia, Parkinson's disease, and urinary incontinence. He is currently hospitalized due to recurrent falls. Prior to his hospitalization, he lived with his daughter and three granddaughters and would like to return to living with them at home. The patient and his care team requested PCA services for 12 hours per day, 7 days per week (84 hours per week). 

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide services 12 hours per day, 7 days per week (84 hours per week) is medically necessary.

There is documentation in the Uniform Assessment System (UAS) of the patient requiring at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time, and the plan failed to document a plan to meet these unscheduled and unpredictable care needs. The plan should not have utilized a tasking tool to calculate hours, given that the patient has unscheduled and unpredictable care needs. The UAS demonstrates a decline in functional status and an increase in assistance needs as compared with the previous UAS. There is documentation from the patient's attending physician of the medical necessity of increased PCA services.

The patient lives with his daughter and therefore has informal support. However, per NYCRR 505.14, the plan cannot assume that the informal support person can provide all needed care outside of the approved PCA hours, as informal support must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bile duct obstruction
Treatment: Continued Stay in Skilled Nursing Facility
The insurer denied: Continued Stay in Skilled Nursing Facility
The denial is upheld.

This adult female patient was admitted to an acute inpatient level of care with bile duct obstruction. She underwent exploratory laparotomy with Roux-en-Y-Hepaticojejunostomy. Her past medical history includes cardiomyopathy, depression, hypertension, panic attack, post-traumatic stress disorder (PTSD), and suicidal ideation. The patient was admitted to a skilled nursing facility (SNF) level of care for nursing and rehab services. Her level of function required moderate assist with activities of daily living (ADLs), and transfer. The health plan covered services through day #26. Services after the approved dates are being appealed. As of the last covered day, the patient was tolerating a regular diet. The patient's level of functioning had progressed to supervised with supine to sit and wheelchair; contact guard assistance with lower body dressing and toileting; and stand by assistance with hygiene. The patient is receiving pan management with oral medications.

The requested health service is not medically necessary. 

This patient was in an acute inpatient level of care for surgical treatment of bile duct obstruction. She was admitted to a skilled nursing facility level of care. As of day #26, the patient was clinically stable. She was not receiving skilled nursing care. Her level of functioning had improved to supervision, stand by, and contact guard assistance with activities of daily living. Her level of functioning did not require ongoing skilled therapy that could only be provided at a skilled nursing facility level of care. Therefore, the continued stay in the skilled nursing facility was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: Low back pain

Treatment: minimally invasive lumbar decompression (MILD)

The insurer denied coverage for minimally invasive lumbar decompression (MILD).

The denial is upheld.

The patient has a history of lumbar spondylolisthesis with facet hypertrophy, synovial cyst and spondylolisthesis. The request is for authorization for minimally invasive lumbar decompression (MILD) procedure.

MILD is appropriate for isolated Ligamentum flavum hypertrophy in the absence of instability or spondylolisthesis. This patient would not meet criteria for MILD procedure. This patient has lumbar spondylolisthesis with facet hypertrophy, synovial cyst and spondylolisthesis. For this patient's clinical scenario there is insufficient clinical trials available. Further studies are needed showing clinical safety and efficacy in this patient's clinical scenario. 

MILD is appropriate for isolated Ligamentum flavum hypertrophy in the absence of instability or spondylolisthesis. This patient would not meet criteria for MILD procedure.     

This patient's condition would be a contraindication to the performance of the MILD procedure.     

The MILD procedure is not the best available treatment for this patient at this time. This procedure would be contraindicated for this patient.     

The adverse risks are increased over standard treatment/services. The risk of decompensation or other complication is greatly increased in a patient with spinal instability, spondylolisthesis and synovial cyst.     

In summary, the denial of minimally invasive lumbar decompression (MILD) procedure and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: minimally invasive lumbar decompression (MILD)

The insurer denied coverage for minimally invasive lumbar decompression (MILD).

The denial is upheld.

This is a patient with a chief complaint of back pain. The patient complains of worsening low back pain with some radiation into the bilateral buttocks. The patient has been treated in the past with epidural injections. The patient has tried and failed physical therapy (PT), home exercises and physician guided therapy for more than 12 weeks. Medications prescribed include gabapentin and Valium. Physical exam notes bilateral paraspinal musculature tenderness to palpation, and positive bilateral facet loading test. Magnetic resonance imaging (MRI) done a few months ago demonstrates multilevel lumbar degenerative disc and facet disease. Mild central stenosis at L (lumbar) 2-L3 with mild compression of the left L2 nerve root. Significant central stenosis at L3-L4 with disc bulging and advanced bilateral facet osteoarthrosis as well as bilateral facet joint effusions was also noted. Significant central stenosis at L4-5 with significant compression of the left L4 and L5 nerve roots, advanced bilateral facet osteoarthrosis, and left facet joint synovial cyst. Disc herniation and facet osteoarthrosis at L5-sacral (S) 1. Multilevel buckling of the ligamentum flavum is noted without mention of ligamentum flavum hypertrophy. The physician recommended the minimally invasive lumbar decompression (MILD) procedure.

The patient has chronic back and leg pain with moderate lumbar spinal stenosis, multilevel bilateral lumbar facet joint arthrosis, multiple lumbar disc herniations, and multiple compressed lumbar nerve roots. The patient has failed conservative treatment including medication, physical therapy (PT), and epidural steroid injections. The physician is recommending the MILD procedure. The procedure does not have approval from regulatory bodies for routine use. This patient's facet joint arthrosis, multiple disc herniations, and nerve root compression would not be addressed by this procedure. The requested procedure is not considered standard of care in the general medical community, as there are significant risks and limitations with this procedure, and it is not found to be more effective than that of a traditional open discectomy. The denial should be upheld.

In summary, the denial of minimally invasive lumbar decompression (MILD) procedure and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
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 male, who initially presented to the emergency department with concerns of chest pain. Pertinent history included hypertension, dyslipidemia, chronic obstructive pulmonary disease, and substance abuse. Initial vital signs revealed a temperature of 98.5F (Fahrenheit), heart rate (HR) 79, blood pressure (BP) 126/87, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 98% (percent) on room air. Initial examination documented tenderness to palpation of the chest wall. Troponin was negative. An electrocardiogram (EKG) was without acute ischemic changes. Chest x-ray (CXR) was unremarkable. The emergency department physician documented an impression of musculoskeletal chest pain with plans to rule out acute coronary syndrome. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a history of hypertension and presented with concerns for chest pain. Initial examination documented the patient as alert, oriented, hemodynamically stable, and with reproducible chest wall tenderness. Initial evaluation revealed a negative troponin, relatively unremarkable electrocardiogram, and relatively unremarkable chest radiograph. Treatment plan included additional diagnostic testing and supportive care. Serial cardiac enzymes remained negative. Echocardiogram revealed a preserved left ventricular ejection fraction without regional wall motional abnormalities. A cardiac stress test revealed a small reversible inferolateral wall defect. Cardiology consulted and did not recommend urgent intervention. Outpatient follow-up was recommended. No other issues or complications were documented. Moreover, clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, respiratory distress, chest pain indicative of serious diagnosis other than coronary artery disease (e.g., aortic dissection, pulmonary embolism), or severe pain requiring acute inpatient management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted Symptomatic Wisdom Teeth

Treatment: D0367 CT (computed tomography) scan.

The insurer denied coverage for D0367 CT (computed tomography) scan.

The denial is overturned.

The patient is under the care of an oral and maxillofacial surgeon (OMS) for the removal of impacted symptomatic wisdom teeth. The lower two wisdom teeth roots are close and possibly overlap the inferior alveolar nerve canal. The Panorex reveals the close proximity of the roots and inferior alveolar nerve (IAN) canal. The surgeon has requested a cone beam computed tomography (CBCT) to assess the true position of the IAN and the roots of the lower wisdom teeth prior to their removal.

In consideration of the clinical standards of the plan, the 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 societies, boards and associations, the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The request for a CBCT is well supported by the records provided. This will allow the surgeon to make the best decision for the patient in regards to the necessary surgery.     

D0367 CT (computed tomography) scan is considered medically necessary for this patient. 
The patient has symptomatic wisdom teeth that require treatment. The OMS has recommended a CBCT to assess the risk of nerve injury. The roots are in very close proximity to the IAN, and the scan is being used to assess how close, and the best possible treatment plan for the patient. 

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 of D0367 CT (computed tomography) scan is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness (diabetes)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male with a past medical history of type 2 diabetes mellitus that was admitted to the hospital with hyperglycemia with associated ketosis and dizziness. The patient was treated with IV (intravenous) fluids and insulin.

The inpatient admission was not medically necessary.

The patient is an adult male with a known history of type 2 diabetes mellitus. He was admitted to the hospital for significant hyperglycemia with associated ketosis and dizziness. The patient had no associated hemodynamic compromise. No tachycardia, hypotension or hypoxia were noted. The patient had a pH (potential of hydrogen) greater than 7.3, and a bicarbonate of 15. Beta hydroxybutyrate was 0.63. The patient responded to treatment with IV (intravenous) fluids and insulin under observation care. The inpatient admission was not medically necessary.