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

Diagnosis: Alcohol Abuse, Hypokalemia.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who initially presented to the emergency department with a request to detoxify from alcohol dependence. His pertinent history included alcohol abuse and diabetes mellitus. He had no history of withdrawal seizures or delirium tremens. The patient was admitted to the hospital. The admitting physician had an impression of alcohol withdrawal, jaundice, and hypokalemia. The treatment plan included a Clinical Institute Withdrawal Assessment (CIWA) with lorazepam as needed, electrolyte replacement, and avoidance of hepatotoxic agents. Gastroenterology consulted and had an impression of alcoholic hepatitis, thrombocytopenia, and alcohol abuse. The Maddrey discriminate function test and Model for End-Stage Liver Disease (MELD) scores were low and corticosteroids were not recommended. Recommendations included vitamin support and an abdominal ultrasound. The abdominal ultrasound revealed focal cortical thickening with a mass effect in the left kidney. Hematology oncology consulted and recommended a computed tomography (CT) scan of the abdomen/pelvis to evaluate the mass. There were no recommendations to directly treat the pancytopenia. There were no visible gross signs of withdrawal other than trivial tremors. Gastroenterology recommended outpatient rehabilitation and signed off. Hematology recommended outpatient follow-up and signed off. Discharge planning was pursued. The patient was discharged. At issue is the medical necessity of an inpatient hospital stay.
Based on the clinical documentation provided, evidence-based literature, and standards of care, the acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient had a history of alcohol abuse and presented with a request for alcohol detoxification. The patient did not have a history of withdrawal seizures or delirium tremens. Initial evaluation revealed pancytopenia and hyperbilirubinemia. Hematology consulted and did not recommend treatment for thrombocytopenia. Gastroenterology consulted and did not recommend treatment for acute alcoholic hepatitis. Laboratory abnormalities improved, with watchful waiting and alcohol avoidance. No CIWA scores of significance were noted. Following observation care, the attending physician documented the patient had no visible gross signs of withdrawal other than trivial tremors, hemodynamics was improved, and oral intake was tolerated. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic Ketoacidosis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is a patient diagnosed with diabetic ketoacidosis (DKA). The patient has a history of gastroesophageal reflux disease (GERD) and type I diabetes and is on an insulin pump. The request is for coverage of inpatient admission. The patient presented to the emergency room (ER) with DKA secondary to running out of supplies for their insulin pump and forgetting to take their insulin subcutaneously (SQ) the night before. The patient had nausea vomiting and epigastric discomfort since the night before. 

The patient's labs on presentation were: glucose 427, acidosis with venous pH 7.22, lactic acid 7.22, anion gap 24, sodium 134, potassium 7.6, chloride 99, carbon dioxide (CO2) 11, blood urea nitrogen (BUN) 12, creatinine 0.92, estimated glomerular filtration rate (eGFR) 88, white blood cell (WBC) 17.9, alkaline phosphatase 190, total bilirubin 2.3, alanine aminotransferase (ALT) 72, bicarbonate (HCO3) 16.  The lab results showed elevated liver function tests.  A urinalysis showed moderate ketones greater than 80.

The patient was treated with intravenous fluids (IVF) and insulin. Two days later, the patient was stable for discharge.

Hospitalization for DKA is universally medically necessary (1-9). Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require Intensive Care Unit (ICU) level care (1,3,4,5) until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care (10,11).  Most hospitals admit patients with DKA to the ICU due to rules regarding the level of service with every-hour blood draws and nursing rules. The patient was admitted because they had diabetic ketoacidosis.  

The patient met the criteria for the diagnosis of DKA based on a glucose 427, pH of 7.22 with an anion gap of 24, and moderate urine ketones greater than 80. The admission is consistent with generally accepted standards of medical practice and is therefore medically necessary. 

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 patient's best interest. 

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

Diagnosis: gastroesophageal reflux disease (GERD)
Treatment: LINX procedure
The insurer denied.
The determination is overturned.

This is a female patient with body mass index (BMI) 25 kilograms per square meter (kg/m2) and history of gastroesophageal reflux disease (GERD) for many years. The patient has been taking proton-pump inhibitors (PPIs) for many years with recent findings of decreased bone density. A 24-hour potential hydrogen (pH) study was positive for pathologic GERD. Esophageal motility was normal. An esophagogastroduodenoscopy (EGD) revealed esophagitis without evidence of Barrett's esophagus. At issue is the medical necessity of the LINX procedure.

Yes. The LINX procedure is medically necessary. The requested procedure is a standard medical treatment for GERD in a patient, without device exclusion. LINX is a standard surgical treatment for GERD within the medical community and is recommended in published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid to long-term outcomes based on published findings. There are only a few exclusions to the treatment which include: Barrett's esophagus with dysplasia, age less than (<) 18 years, prior bariatric or gastric surgery and BMI greater than (>) 35 kg/m2. This patient has no documented treatment exclusions. The patient has long standing GERD with the inability to continue with PPIs secondary to bone loss. The patient requests a surgical treatment for GERD and LINX is an appropriate and standard treatment for GERD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, malaise.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with stage IV diffuse large B cell non-Hodgkin lymphoma. The patient has received multiple lines of therapy and is currently on epcoritamab. The patient presented with a subjective fever for two days associated with malaise and dysuria. The patient has no other symptoms. The patient's laboratory studies were unremarkable except for a urinalysis with large amounts of leukocytes. Her exam was without pertinent positives. The patient's imaging did not demonstrate any acute processes.
The patient was admitted for inpatient care. She was started on antibiotics and cultures were obtained. She was ultimately discharged to home on Cipro. The patient was discharged; inpatient care is under review for medical necessity.
The inpatient admission was not medically necessary for this patient.
This patient is stated to have had "neutropenic fever" on the admitting history and physical and was admitted for inpatient care to address this. However, the patient was neither neutropenic nor ever documented to have had a fever. The patient had no evidence of infection requiring inpatient care or parenteral antibiotics. The patient did not receive intervention requiring inpatient care. The majority of the services provided (antibiotics, intravenous (IV) fluids, and nursing) were supportive. She was ultimately discharged on oral antibiotics. Support for inpatient care in the peer-reviewed literature is sparse. For these reasons, the medical necessity for this hospitalization has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Radiofrequency Ablation  
The insurer denied Radiofrequency Ablation 
the health plan's determination is upheld.

This is a female patient diagnosed with low back pain. According to the records, the patient was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance carrier as experimental and investigational.
It was noted the patient has a history of low back pain that began in 2018. She has tried heat, ice, home exercises, lumbar epidural injection, medication management and physical therapy. Medications have included celecoxib, naproxen, trazodone and Tylenol. Pain is impacting activities of daily living and nothing has provided significant sustainable relief. The provider notes the patient had an magnetic resonance imaging (MRI) performed on 5/5/23 demonstrating Modic I type changes at disk space is L (lumbar)5 - S (sacral)1 and the provider believes that this is the source of her chronic back pain.

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 persistent low back pain and has tried conservative treatment including physical therapy, exercises, lumbar epidural injection and medications. 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). It should be noted however that the patient also has findings of disc herniation at L4 - L5 as well as annular fissure L5 - S1 and varying degrees of spinal canal and neural foraminal narrowing which are quite likely pain generators as well. 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 safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Radiofrequency Ablation  
The insurer denied Radiofrequency Ablation 
the health plan's determination is upheld.

The patient is a female with a chronic history of low back pain. Her pain began in 2018. Prior treatment has included epidural injections, medications, and physical therapy. The pain significantly impacts her activities of daily living. A magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type I changes at disc spaces L (lumbar) 5-S (sacral) 1.

The proposed Radiofrequency Ablation 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. The request is for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A 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: Radiofrequency Ablation  
The insurer denied Radiofrequency Ablation 
the health plan's determination is upheld.

This patient is a female who has chronic lower back pain. Her pain started while she was working out in a gym and felt a pop in her back. She has been taking Celebrex on an as needed basis with moderate pain relief. She describes her pain as sharp aching in the back with occasional radiating pain down to the lower extremities. Her pain is worsened with forward bending, prolonged sitting, standing and walking. Her prior treatments included heat, ice, naproxen, Tylenol, physical therapy, home exercise and epidural steroid injection. She had some improvement with these conservative treatments. Physical examination revealed tenderness over the lumbar paraspinal region, pain with extension rotational movement, and negative straight leg raise bilaterally.

Radiofrequency Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Radiofrequency ablation of basivertebral nerve was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has significant disc herniations at L4-5 and L5-S1 levels with central canal and foraminal narrowing. She responded to prior conservative treatments including an epidural steroid injection, which indicated that lumbar disc herniations and lumbar radiculitis are potentially significant pain generators. Truumees's study supported the efficacy of the Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded from the study.
Given this patient's medical history, MRI reading, and the exclusion criteria of current clinical studies, it is unlikely that the proposed radiofrequency ablation procedure is likely to be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crossbite
Treatment: D8080 Braces
The insurer denied: D8080 Braces
The denial is upheld.

This case involves a teenage female. The appeal is in regard to the denial of comprehensive orthodontic treatment. The initial review denied treatment due to documentation not meeting the clinical criteria for comprehensive orthodontic treatment of the adolescent dentition. The provider states an automatic qualifier of a crossbite of individual anterior tooth is present. The initial review gave a score of 19.

The requested health service is not medically necessary.

Orthodontics are allowed with medical necessity based on the Handicapping Labio-Lingual Deviation (HLD) index. A score of 26 or an automatic qualifier condition must be present. The provider states tooth #(number) 22 is in crossbite, but a review of the photographs does not show a complete anterior crossbite. The patient's score of 19 is confirmed. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary artery disease.
Treatment: Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 49 Hours per Week.

The insurer denied Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 49 Hours per Week.  The health plan's determination is overturned. 

This is a male patient with a history of coronary artery disease, diabetes mellitus type 2 with diabetic neuropathy, hypertension, hyperlipidemia, hypothyroidism, mild intermittent asthma, gastroesophageal reflux disease (GERD), and osteoarthritis of bilateral knees. The patient is requesting Consumer Directed Personal Assistance Services (CDPAS).

Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS): Increase to 49 Hours per Week are medically necessary for this patient.
There is documentation in the recent UAS (uniform assessment system) of the patient requiring at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. Although the patient lives with his wife and therefore has informal support, it cannot be assumed that the informal support person can provide all needed care outside of the approved CDPAS hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA (personal care assistant) 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: chest pain
treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who presented to the emergency department (ED) with one week of chest pain. His chest pain was described as intermittent, pressure like chest pain with radiation to the left arm, started last week and worsened in the morning. His pain was 7/10. His pain was worsened by deep breathing, and he also had palpitations. 

The requested Inpatient Hospital Admission is not medically necessary for this patient. The patient presented with chest pain, which was, most likely, not cardiac. He had a pleuritic component to it. His ECG was normal, and troponin was normal.
The patient's condition was stable, and his vital signs were normal. The patient, considering his coronary risk factors of HLD and family history for coronary artery disease (CAD), should have been observed for 24 hours and discharged if the work up was negative. In this case, the delay of discharge was due to a delay of care.
However, that delay of care does not elevate the level of care to inpatient. The patient could have been discharged after 24 hours of observation and the stress test could have been arranged as an outpatient. The inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 49 Hours per Week.
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 49 Hours per Week.
The health plan's determination is overturned. 

The patient is a female with a past medical history of vascular dementia, depression, anxiety, hypertension, coronary artery disease, gastroesophageal reflux disease (GERD), hyperlipidemia, osteoarthritis, osteopenia, rheumatoid arthritis, and urinary incontinence who had been assigned PCA (personal care aide) services.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 49 Hours per Week are medically necessary for this patient.
There is documentation from the patient's psychiatrist and PCP (primary care provider) of the medical necessity of increased PCA (personal care aide) services due to a deterioration of functional and cognitive status. In addition, the patient's son is unable to provide informal support outside of the currently assigned PCA services due to the need to care for his own family and work. Despite documentation from the patient's medical providers and family, there was a decrease in assistance needs with tasks of meal preparation, ordinary housework, personal hygiene, dressing upper body, and toilet use when comparing the most recent assessment from the previous assessment. The current assessment underestimated the patient's assistance needs with toilet use. The patient 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 requested increase in PCA services and thought solely for safety and supervision but to assist the patient 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, the requested services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Home health care - Personal Care Services 40 Hours Per Week.
The insurer denied Home Health Care - Personal Care Services 40 Hours Per Week.
The health plan's determination is upheld. 

This is a male patient with a history of coronary artery disease, congestive heart failure, aortic aneurysm, hyperlipidemia, hypertension, type 2 diabetes mellitus, back pain, chronic pain of both knees, and memory loss. The patient was assessed at maximal assistance for ordinary housework and shopping; extensive assistance for meal preparation; limited assistance for managing medications, managing finances, stairs, dressing lower body; supervision for transportation and bathing; setup help only for dressing upper body, walking, locomotion, toilet use; and independent for phone use, personal hygiene, transfer toilet, bed mobility, eating. A tasking tool was used to determine that he requires 15.08 hours of aide service per week.

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, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 40 Hours per Week is not medically necessary.
The documentation provided does not indicate a reason that he requires an increase in personal care hours or what needs are not being met by his current number of care hours. He is continent of bowel and bladder and per most recent Uniform Assessment System (UAS), he requires only setup help for walking, transfer toilet, and toilet use and so he does not have any unscheduled or unpredictable care needs. Although the patient does require limited assistance with bathing and dressing the lower body, these needs could be met with the current number of personal care hours approved by the insurer.