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

Diagnosis: CPP (central precocious puberty)
Treatment: Triptodur
The insurer denied Triptodur. The health plan's determination is overturned. 

This is a female diagnosed with CPP (central precocious puberty). This request is for Triptodur. 

Triptodur is medically necessary for this patient.
The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 in girls and younger than age 9 in boys. Central precocious puberty (CPP) is diagnosed using a basal luteinizing hormone (LH) of greater than 0.3 or stimulation testing with a gonadotropin-releasing hormone (GnRH) analog such as luprolide showing a pubertal response defined as an LH greater than 5 or estradiol greater than 40. CPP is treated with GnRH agonists such as lupron, Triptodur, and supprelin. The Food and Drug Administration (FDA) indication for GnRH agonists is for use in central precocious puberty (CPP). In addition, when used for CPP, the FDA recommends discontinuation of GnRH agonists before age 11 for females and before age 12 for males. This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone age of 12 in girls and 13 in boys.
The patient's exact onset of secondary sexual characteristics is not clear. However, the normal time interval between onset of thelarche and menarche is 2.5 years. This patient had menarche at age 9. The Onset of secondary sexual characteristics likely began at age 6.5 or 7 years. The patient has a pubertal luteinizing hormone (LH). The use of Triptodur is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: congestive heart failure
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week. The health plan's
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, asthma, diabetes mellitus type 2, chronic diastolic heart failure, hyperlipidemia, dementia, osteoarthritis, hearing loss, urinary incontinence, and vitamin B12 deficiency who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services.

Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week are medically necessary for this patient.
There is documentation of worsening physical and cognitive functioning by the patient's provider, daughter, and the plan's own assessment. The patient had an increase in assistance needs specifically with tasks of meal preparation, shopping, transportation, walking, locomotion, transfer toilet, and toilet use when comparing previous assessment tools. The patient requires at least maximum assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The insurer assumed the patient had informal help outside of the currently assigned CDPAP hours which was not the case. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

The patient is a female with complaints of low back pain. The pain began 5 years ago. Treatment has included therapy, injections, medications, as well as home exercises. She has failed opioids, as well as muscle relaxants. Pain ranges from 7-9 out of 10. Her activities of daily living (ADL) are restricted secondary to the pain. Magnetic resonance imaging (MRI) lumbar spine was performed and demonstrated degenerative changes at L (lumbar)5 and S (sacral)1.

The proposed Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. This procedure is not recommended despite promising early reports, and further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

The patient is a female with diagnoses of Lumbar Radiculopathy, Lumbar Facet Arthropathy, and Vertebrogenic Low Back Pain. The patient was recommended to undergo the Intracept procedure (interosseous basivertebral nerve ablation), which was denied by the insurance carrier as experimental and investigational. This determination is under appeal, which is the subject of this review.

The Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). Although there was documentation of Modic changes on MRI that are likely causing pain, there were also multiple other pain generators noted on MRI including multilevel disc herniations with nerve impingement at multiple levels. This procedure is not standard of care as there is a lack of high-quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish its safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a female who has low back pain and neck pain with radiating pain down to the right arm. She has low back radiating pain to the right posterior thigh. Her back pain is worse with standing, sitting to standing, and walking. She has deceased function with limitations on activities of daily living (ADL) and quality of life (QOL) due to pain. Her current pain medications keeps her functions without significant side effect. 

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. The available medical records did not reveal adequate evidence that vertebrogenic pain is the primary pain generation. This patient has low back radiating pain to the right posterior thigh. The prior RFA (radiofrequency ablation) of facet joints provided her with one year of pain relief. An magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease (DDD), L (lumbar)4/5 disc bulge and facet hypertrophy with a left foraminal herniation and impingement of left L4 nerve, a disc bulge and facet hypertrophy at L5/S (sacral)1 level with bilateral foraminal encroachment and displacement of right L5 nerve root, and Modic changes at L5/S1. Truumees's study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.
Given this patient's medical history, MRI reading, and the current clinical evidence, the proposed Intracept Procedure is not likely to be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right flank pain.
Treatment:  Inpatient admission.

The health plan denied inpatient admission. The denial is upheld.

The patient is an adult male. He presented to the ER (emergency room) with complaints of right flank pain.

On presentation, the patient was afebrile and hemodynamically stable. His associated symptoms included nausea. CT (computed tomography) scan showed 8 mm (millimeter) right mid to distal ureteral stone with severe hydronephrosis. WBC (white blood cell) count was 20.

The patient was admitted on the inpatient service and underwent cystoscopy with right ureteral stent placement. He had an uneventful hospital stay and was discharged home the next day. Medical necessity of the inpatient stays is under review.

The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis (done next day). The procedure performed is considered a minimally invasive outpatient procedure, and as such, in the absence of a "high risk surgical patient," it does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care.

Observation status for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation, if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: peripheral vascular disease 
Treatment: Outpatient Ambulatory Surgery [Blood Vessel Procedure (37226, 37224, 37228) x 1]
The insurer denied Outpatient Ambulatory Surgery [Blood Vessel Procedure (37226, 37224, 37228) x 1].
The health plan's determination is overturned. 

The patient is a male with multiple medical problems and peripheral vascular disease and claudication. The patient has had previous stents in his superficial femoral arteries.
A computed tomography (CT) angiogram of the abdominal aorta and bilateral lower extremity runoff demonstrated:
Right side: multifocal moderate stenosis proximal to mid right femoral artery. Patent stent with multilevel moderate stenosis with severe stenosis distally with possible additional severe stenosis distal to this. Calcific plaquing with narrowed proximal peroneal artery which is patent to the ankle.
Left side: moderated stenosis proximal common iliac artery. Left femoral artery stent demonstrates a severe stenosis at the origin at the junction of the common femoral superficial femoral arteries. There appears to be probable additional severe stenosis at the distal aspect of the stent. Three vessel runoff.

Outpatient Ambulatory Surgery (Blood Vessel Procedure) is medically necessary for this patient.

The patient has claudication due to peripheral arterial disease and has had prior interventional treatment. CT angiogram documented bilateral lower extremity arterial disease. The treatment is medically necessary. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee pain.
Treatment: Inpatient admission.
The health plan denied inpatient admission. 
The denial is overturned.

The patient is an adult male with knee pain. He has a history of severe morbid obesity, hypertension, and non-ischemic cardiomyopathy. He had undergone a left total knee replacement last year complicated by pain and decreased motion. He had undergone MUA (manipulation under anesthesia) x 2.

The patient was admitted to the hospital and discharged two days later. His surgery was arthrotomy, synovectomy and arthrolysis. He required PCA (patient-controlled analgesia), CVAC (Central Venous Access Catheter) and monitoring after the procedure.

The records show a complex and unique clinical condition to warrant the services provided. The important findings to substantiate inpatient admission are as follows:
BMI (body mass index) 45. This is an outlier to ambulatory arthroplasty. The patient would be at extremely high risk for complications.
The anesthesia time was nearly 5 hours. The patient has COPD (chronic obstructive pulmonary disease) with reported need for CPAP (continuous positive airway pressure). There would be an increased risk of pulmonary problems.
The patient had a drain in place with continued output. A special VAC (vacuum-assisted closure) drain was placed. It was not removed until POD (post-operative day) #2. A patient would not be able to be discharged with active drainage.
The patient was also found to have continued pain to require PCA (patient-controlled analgesia).

Based upon the described clinical condition, the inpatient admission and length of stay was warranted and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oxygen desaturation 
Treatment: Medical equipment: home oxygen concentrator (E1390RR x6) 
The insurer denied coverage for medical equipment: home oxygen concentrator (E1390RR x6). 
The denial is upheld. 

This patient has a diagnosis of deep vein thrombosis and bilateral pulmonary embolism. The patient underwent thrombectomy for clot removal, subsequently on anticoagulation. The patient was also reported to have some pulmonary hypertension and during a subsequent office visit noted to have oxygen saturation (sats) of 94% (percent) on room air which dropped to 87% on exercise. The patient was recommended home oxygen (O2). This patient was prescribed an oxygen concentrator. 

An oxygen concentrator is indicated for people who need continuous O2 supplementation. 

This patient did not have any hypoxia at rest and needed O2 only on exercise/ambulating. 

She did not need a concentrator. She would benefit from portable O2 given by a nasal cannula during exercise. She was maintaining O2 sats of 96% on 2 liters (L) while ambulating. She could have had oxygen via a portable cylinder or cannister to be used while ambulating. She did not need O2 supplementation at other times. 

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 medical equipment: home oxygen concentrator (E1390RR x6) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain. 
Treatment: Inpatient Hospital Admission. 

The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is upheld. 

The patient is a male with a medical history of diabetes mellitus type 2, alcohol use disorder complicated by prior withdrawal, partial pancreatic resection complicated by chronic pancreatitis, and insomnia. He presented to the emergency department with severe epigastric pain radiating to his back for two days, with the onset after drinking alcohol, and nausea and vomiting. He had been admitted a month ago with similar symptoms. Vital signs were notable for tachycardia with pulse rate of 134/minute. Physical examination was notable for the patient being in acute distress, generalized epigastric abdominal tenderness, and guarding. Labs showed a low white blood cell count of 4.3 , a low platelet count of 119 , and an elevated alanine aminotransferase of 71; the lipase was normal. A computed tomography scan of the abdomen and pelvis showed clear lungs without pneumoperitoneum or visceral distention in the upper abdomen. He was treated with intravenous fluids, Ondansetron, Morphine, and oral Librium. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. He reported ongoing pain; no withdrawal symptoms were noted. The next day he reported ongoing pain, and he was tolerating a regular diet; no withdrawal symptoms were noted. The patient was discharged with a plan for Primary Care and Gastroenterology follow-up. 

At issue is the medical necessity for the inpatient hospital admission. 

The health plan's determination of medical necessity is upheld, in whole. 

The inpatient level of care is not supported, and the care provided could have been provided at an alternative level of care. 

In this case, the patient presented with abdominal pain consistent with acute pancreatitis, although imaging and lipase were unremarkable in the setting of a partial pancreatic resection complicated by chronic pancreatitis. [1-3] He did not have any complications of pancreatitis such as pancreatic necrosis, pseudocyst, or abscess. [4-6] No procedural interventions such as endoscopic ultrasound were necessary. He was appropriately treated with intravenous fluids, and his symptoms improved; his diet was advanced and discharge was then deemed appropriate. He noted alcohol use prior to onset of symptoms, but there was no acute liver failure or alcoholic hepatitis. [7,8] He was monitored for possible alcohol withdrawal, but no protracted or severe acute alcohol withdrawal was documented. [9,10] The interventions performed, including labs, monitoring, imaging, CIWA protocol, and Gastroenterology consultation, could have been performed without the inpatient level of care, at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pelvic pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.
 
The patient was an adult female with complaint of pelvic pain who underwent a total laparoscopic hysterectomy. The procedure was uncomplicated. Post-operatively, the patient was stable. She was discharged home.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic supracervical hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines, Inpatient and Surgical Care 26 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for, surgical complications (bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, complex surgery (staging of endometrial cancer), wound complications, and comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. Nothing in the submitted clinical information suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. The length and the complexity of the surgery did not warrant hospital admission.

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

Diagnosis: Post-vaccination encephalitis, autoimmune encephalopathy. 
Treatment: Gammunex-C. 

The health plan denied Gammunex-C. 
The denial is upheld. 

The patient is an adult female who reported cognitive dysfunction and gait impairment after vaccination for COVID19 (coronavirus disease 2019). MRI (magnetic resonance imaging) brain was reported as normal. CSF (cerebrospinal fluid) studies were reported as normal. Video EEG (electroencephalogram) monitoring was reported as normal. The provider has diagnosed her with post-vaccination encephalitis, autoimmune encephalopathy. She has been treated with steroids. The provider is requesting Gammunex-C IVIG (intravenous immunoglobulin). 

The patient does not meet the accepted diagnostic criteria for autoimmune encephalitis. Specifically, she has a normal MRI (magnetic resonance imaging), EEG (electroencephalogram) and CSF (cerebrospinal fluid) studies, and there is no documentation of an elevated CSF (cerebrospinal fluid) or serum antibody titer to identified antigens associated with this condition (Abboud et al., 2021; Fernandez-Fournier et al. 2022). The PET (positron emission tomography) scan and cytokine panel are not diagnostic of autoimmune encephalitis. Therefore, she does not have a condition that amenable to treatment with IVIG (intravenous immunoglobulin) (Lee et al., 2022). There are no clinical trials or standard of care guidelines to support the use of IVIG (intravenous immunoglobulin) for her condition.