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

Diagnosis: Respiratory System/Asthma
Treatment: Inpatient Hospital

Diagnosis: Respiratory System/Unspecified Asthma with (Acute) Exacerbation
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is upheld.

This case involves a woman with a history of asthma who presented to the hospital with complaints of back pain and shortness of breath. The symptoms began ten days before presentation, with sharp 10 out of 10 pain radiating down both legs, more prominent on the left side. The left leg felt weaker, but the patient was able to ambulate. She had spinal surgery ten months before this presentation without resolution of the chronic back pain. During the previous week, the patient was also treated with Amoxicillin for the development of a greenish productive cough, which was slowly improving. She did experience some wheezing related to her asthma, runny nose, and sore throat.

Laboratory studies included a leukocytosis of 15.8, with a stable hemoglobin. The electrolytes were fairly stable, with a creatinine of 0.8. A chest x-ray was obtained and was unremarkable, and so was the urinalysis. She was given Solu-Medrol 40 milligrams (mg) every 8 hours, Lorazepam 1 mg intravenous (IV) every 8 hours for anxiety, and Ceftriaxone plus Doxycycline for unclear reasons.

The patient reported feeling better, breathing easier, and having no new complaints. Vital signs appeared stable. The respiratory exam showed scattered rhonchi, but she was overall stable. The patient was deemed stable for discharge. She was released on a Prednisone taper, Flexeril, Meloxicam, Gabapentin, and Oxycodone. Antibiotics were not prescribed, as there was no evidence of pneumonia.
At issue is the medical necessity for the inpatient hospital admission.

I fully uphold the health plan's determination of medical necessity.

From an asthma standpoint, the patient remained on room air throughout the hospitalization and did not require invasive or noninvasive asthma exacerbation treatment. The viral panel was negative. A chest x-ray was clear for concurrent pneumonia, which would complicate the asthma exacerbation. Peak flows are not documented. The medical documentation fails to demonstrate the severity of the asthma exacerbation to qualify for an inpatient hospitalization.
Overall, the patient's condition gradually improved over the hospital stay, with no evidence of life-threatening symptoms. The progress notes state the patient's condition improved daily until she was eventually released home. Therefore, inpatient criteria are not satisfied, and an alternate level of care would have been appropriate to manage the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Renal Disease
Treatment: Hospital Services
The insurer denied: Hospital Services
The denial is: Upheld

The patient is a female with a past medical history significant for stage five (V) chronic renal disease with confirmed focal sclerosis, anti-nuclear antibody (ANA) positivity, and medical noncompliance who presented to the emergency department with decreased energy levels and generalized weakness. The patient was initially seen by a nephrologist who referred the patient to the hospital due to severe anemia, severely elevated creatinine levels, and hyperkalemia. The patient agreed to a blood transfusion and received 2 units of packed red blood cells. As a result of the blood transfusion, her hemoglobin went up to 7.8.
The patient was offered hemodialysis. General surgery was consulted for hemodialysis access.
The patient initially agreed to have hemodialysis access established, but when surgeons came to her room, she refused the placement of a hemodialysis catheter.
During the hospital stay, the patient was seen by the psychiatrist service who determined that the patient had the capacity to make her own decisions and refuse hemodialysis.
At the end of the hospitalization the patient left the hospital against medical advice, the next day after admission.

The requested hospital services was not medically necessary for this patient. The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The patient presented to the hospital with anemia, however, there was no evidence that the anemia was associated with hemodynamic instability, active bleeding, or hemolysis. The anemia was not associated with altered mental status, recurrent syncopal, or near syncopal episodes. There was no evidence of high-risk low platelet count. The anemia was not associated with acute renal failure. The patient had chronic kidney disease and was offered hemodialysis. There was no evidence of heart failure, myocardial ischemia, acute peripheral ischemia, or any other signs of symptoms requiring intervention at the acute inpatient level of care.
Overall, the patient remained in stable clinical condition and did not receive any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
The hospital stay was short, and based on the complexity of services provided could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia 

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is pediatric patient with a history of a dry cough for one week. The child had green mucous draining from the eye and fever. The child had coughing spells and was weak and lethargic. The child was seen by the pediatrician and was started on antibiotic eye drops. When the oral intake of fluids decreased the mother returned to the pediatrician who administered a nebulizer treatment in the office and recommended that the child be taken to the emergency room (ER) for additional treatment.

In the ER the child was noted to have conjunctivitis and to be short of breath. The pulse oximeter reading was 98%. A chest x-ray showed evidence of an atypical pneumonia with areas of ground glass opacity. The blood testing showed a bicarbonate level of 15, a Blood Urea Nitrogen (BUN) of 17, a C-reactive protein (CRP) of 5.2 and a procalcitonin of 2.73. The urine specific gravity was elevated. A respiratory viral panel was positive for parainfluenza virus. Based on the lab test results and the chest x-ray finding of bilateral pneumonia the decision was made to admit the child to the hospital with a diagnosis of pneumonia for treatment with intravenous (IV) fluids, azithromycin, and ceftriaxone.

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 a parainfluenza viral illness and increased work of breathing. The child tested positive for parainfluenza virus. The child was not treated with an IV bolus of normal saline to treat possible dehydration as suggested by a decrease in oral intake, a high specific gravity, and a low bicarbonate level of 15. The child was not in acute respiratory distress, and the child could have been discharged on oral antibiotics for atypical pneumonia with a follow up with the pediatrician in 24 to 48 hours. The decision to admit was based on the chest x-ray finding but there was no requirement for oxygen supplementation because the pulse oximeter reading had been in the normal range.

The decision to admit to the hospital was not consistent with the standard of care for a viral illness with the parainfluenza virus. This child could have been safely observed in the ER and treated with a bolus of normal saline. 

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: Dental issues
Treatment: Full Braces and Monthly Brace Adjustment Visits
The insurer denied full braces and monthly brace adjustment visits.
The health plan's determination is upheld.

The patient is a male with Class II malocclusion with mild maxillary spacing and mild mandibular crowding. There is moderate overjet and severe overbite. The patient has ectopic and delayed formation of the mandibular second premolars with retained mandibular primary second molars. The subject to be determined is if the requested health service/treatment of full braces and monthly brace adjustment visits are medically necessary.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin. Auto qualifiers also include severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The patient's malocclusion does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for full braces and monthly brace adjustments are not medically necessary.

The health plan's determination is upheld, in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain
Treatment: Intraosseous basivertebral nerve ablation (procedure code 64628)
The insurer denied coverage for intraosseous basivertebral nerve ablation (procedure code 64628)
The denial is upheld

This patient has chronic low back pain. He has tried dry needling, Physical therapy, Chiropractic therapy, a Home exercise program as well as Heat and Ice. He has had diagnostic medial branch blocks (MBBs) and the radiofrequency ablation (RFA) of his facet joints. He is not taking pain medications currently. His magnetic resonance imaging (MRI) shows lumbar (L)5 and sacral (S)1 Modic changes. It is also notable that he has an L5-S1 central disc extrusion with stenosis and S1 nerve root impingement. No surgical consultation is documented. The request is for RFA of the Basivertebral nerves (BVN) at L5 and S1.
	
Conger pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Urits also commented on the need for more research on this promising technique: "reproducible large RCTs (randomized control trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF (radiofrequency) ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

This procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of intraosseous basivertebral nerve ablation (procedure code 64628) 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: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is overturned.

This is a female patient with obesity treated with Wegovy. She is followed by an obesity medicine specialist and registered dietician. She is following a prescribed diet and exercise program. Her weight is 220 pounds (lbs), body mass index of 36.6 kilograms per square meter (kg/m2). The request for continuation of Wegovy 2.4 milligrams (mg) weekly is under review for medical necessity.

The requested Wegovy is medically necessary. This request is for Wegovy for the treatment of obesity. The prior request was denied because the patient has not participated in a comprehensive weight management program for at least 6 months prior to using drug therapy. The Endocrine Society guidelines on the management of obesity indicate that diet, exercise, and behavioral modification should be included in obesity management and pharmacotherapy can be used as an adjunct to these measures as drugs may amplify adherence to behavior change and may improve physical functioning. These guidelines indicate that patients who have a history of being unable to successfully lose and maintain weight loss and who meet label indications are candidates for weight loss medications. The patient has tried and failed lifestyle changes. She has been managed by an obesity medicine specialist and registered dietician. This patient is obese with a body mass index of 36.6 kg/m2. Additional lifestyle changes alone through a comprehensive weight management will not reasonably allow patient to reach a goal of a BMI (body mass index) of less than 30 kg/m2. Without Wegovy, this patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes. Therefore, the requested Wegovy is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy
Treatment: Consumer Directed Personal Assistance Services: Total of 56 Hours per Week
The insurer denied Consumer Directed Personal Assistance Services: Total of 56 Hours per Week.
The determination is overturned.

This is a male patient who was diagnosed with Duchenne Muscular Dystrophy. He uses a wheelchair. He has severe scoliosis with thoracic kyphosis. He is being evaluated for corrective spine surgery. Cardiac magnetic resonance imaging (MRI) shows extensive fibrosis, indicative of cardiomyopathy. Pulmonary function tests indicate severely decreased respiratory muscle strength testing, with a severe restrictive pattern on spirometry. He has moderate obstructive sleep apnea. He does not cough or choke on food, and eats by mouth. He uses a cough assist device twice daily, and non-invasive ventilation (BiPAP) at night. His mother wakens at least twice a night to turn him, and to check his bi-level positive airway pressure (BiPAP).
He lives with his parents in a single level house with ramp access. He  has a power wheelchair. He has Dynasplints. He is able to feed himself, but he is totally dependent for turning in bed (his mother gets up to turn him at least twice a night) and he requires two person transfer or use of a lift at home. Durable medical equipment includes a shower bench. His mother is his primary caregiver. He receives an aide through Consumer Directed Personal Assistance Services for 5 hours, 7 days per week, between the hours of 4 PM and 9 PM. 
His neuromuscular team has recommended that he receive Consumer Directed Personal Assistance Services: Total of 56 Hours per Week. The medical necessity of this service is the issue for review.

The requested health service/treatment of Consumer Directed Personal Assistance Services: Total of 56 Hours per Week is medically necessary for this patient, The patient's medical needs for care cannot be met with his current 35 hours per week of Consumer Directed Personal Assistance Services. The requested 56 hours per week are medically necessary. At present, his mother is transferring him from bed to chair without assistance in the morning. Given his size, this is unsafe, and puts him at risk for falls. In addition, the current 35 hours of Consumer Directed Personal Assistance Services does not cover night time, during which his bi-level positive airway pressure (BiPAP) device needs to be checked and readjusted as necessary, and he needs to be turned to prevent the development of pressure sores. He requires supervision for eating and taking medication, as he is at risk of choking, given his severely impaired respiratory function.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied the braces and monthly visits.
The determination is overturned.

This is a female patient with a class II divison 1 malocclusion with maxillary spacing and mandibular crowding. She has a 9 millimeter (mm) overjet and 6 mm overbite. She is treatment planned for 30-36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits. 

This patient, like fifteen percent of the population, exhibits an Angle's class II bite. (1) Patients with a class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with a 6 plus (+) mm overjet, which this patient has. (3) For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: difficulty swallowing.
Treatment: inpatient stay.
The insurer denied an inpatient stay. 
The health plan's determination is upheld. 

This case involves a woman admitted to the hospital with painful and difficult swallowing. The patient has experienced odynophagia for three weeks and had been treated with azithromycin for strep throat through an urgent care center, though a rapid strep test was negative. There was no improvement with the antibiotic. Associated symptoms included five days of chills, night sweats, nonproductive cough, and generalized malaise. She has difficulty eating solid foods and only takes liquids. The patient has underlying human immunodeficiency virus (HIV) and is receiving therapy. 

Based on the provided documentation, inpatient hospital admission was not medically necessary. A lower level of care would appropriately addresses the patient's acute medical needs. Oral candidiasis was rapidly improved with the initiation of appropriate antifungal therapy. There is no evidence of severe electrolyte derangements or dehydration related to an inability to tolerate solid foods before arrival. There are no other secondary infections related to a low CD4 (cluster of differentiation 4)count. The patient remained hemodynamically stable without evidence of sepsis during the 24-hour hospitalization. There are no documented needs for urgent endoscopic evaluation, gastrointestinal (GI) bleeding, or gastrointestinal tumors. There is ample evidence that the patient's condition rapidly improved in the observation timeframe, with a subsequent transition to an outpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
inpatient hospital

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

The patient is a male child who presented to the emergency department (ED) via Emergency Medical Services (EMS) with full body stiffening, desaturation to 62%, and tachycardia to 242 that began while he was sleeping. EMS treated him with albuterol and supplemental oxygen with improvement in breathing. Vital signs included temperature 37.4, heart rate 134, respiratory rate 20, and oxygen saturation 97%. Examination was significant for no acute distress, non-toxic appearance, ear tubes present bilaterally with no drainage seen, rhinorrhea, moist mucous membranes, clear lungs, benign abdomen, brisk capillary refill, moving all extremities, good strength with some weakness on the left at baseline.

The inpatient hospital admission was not medically necessary for this patient.

This young male child with congenital brain abnormalities and known seizures presented with breakthrough seizure-like activity. There were no significant changes on magnetic resonance imaging (MRI) and ventriculoperitoneal (VP) shunt series was negative. His carbamazepine dose had been increased by his primary physician on the day of presentation and the serum level obtained was within normal limits but at the low end of the reference range, likely not yet fully representing the increase in dosage. While it was reasonable and medically necessary to monitor him in the hospital to monitor for episodes of apnea and seizure, he was overall hemodynamically stable with no mental status changes or changes in behavior, and no evidence of shunt failure or infection. He did not require acute inpatient admission and could have been safely managed at lower level of care.