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

Diagnosis: Inability to close the left eyelid associated with a left-sided facial droop.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a male patient with a past medical history (PMH) of transient ischemic attack (TIA) and gastroesophageal reflux disease (GERD) who was admitted with complaints of (c/o) the inability to close the left eyelid associated with a left-sided facial droop. His vital signs were unremarkable. The physical exam was notable for awake, alert, and oriented times three (AAOx3), normal strength and sensation, unable to close left eyelid or wrinkle left half of forehead. Lab work was unremarkable. Imaging studies, computed tomography angiography (CTA) of the head/neck showed no acute intracranial process, magnetic resonance imaging (MRI) of the brain showed no evidence of restricted diffusion or gross intracranial hemorrhage, MRI of the cervical (C)-spine showed a moderate to large central disc protrusion with spinal cord compression. The patient was diagnosed with Bell's Palsy versus Lyme disease and treated with pain control, physical therapy (PT) / occupational therapy (OT), and steroids. Neurosurgery evaluated the patient for MRI findings and recommended no acute neurosurgical intervention. The patient was discharged 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. This patient presented to the emergency department (ED) with complaints of (c/o) the inability to close the left eyelid associated with a left-sided facial droop. The patient was initially suspected of having a stroke but was eventually found to have a negative computed tomography (CT) scan and MRI negative for acute ischemia. Further suggestion that this patient was appropriate for observation care is that the patient did not have a crescendo transient ischemic attack (TIA). head CT/MRI was negative, there was no known extracranial embolic source, such as atrial fibrillation or artificial heart valve, known carotid stenosis, disabling stroke, altered mental status, or hypertensive encephalopathy. The patient remained hemodynamically stable during the stay, was treated with a standard work-up for TIA, but was eventually diagnosed with Bell's palsy, not TIA or CVA, and was discharged in stable condition after a good response from administration of steroids. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bilateral flank pain and fever

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult male with a past medical history of diabetes, recurrent urinary tract infection, hypertension, Lumbar 1 (L1) spinal cord injury, paraplegia, respiratory failure status post cerebral vascular accident (CVA), status post supra pubic tube placement, who presented to the emergency department (ED) with bilateral flank pain, complaint of fever, diarrhea, and no supra-pubic (SP) tube change for 5 weeks. The patient was afebrile in the emergency room, blood pressure was 138/84 millimeters of mercury (mmHg), urinalysis showed nitrate positive, white blood cell (WBC) count >50. Computed tomography (CT) scan showed non obstructing right renal calculi, no evidence of pyelonephritis, no ureteral or bladder calculi, supra-pubic tube in place. 

The patient given intravenous fluids and intravenous Rocephin in the emergency room and was admitted for further treatment. The patient improved and was discharged home, with outpatient follow up with primary care physician and urology. 

The patient fails to meet clinical indications, by Milliman Care Guidelines (MCG) for admission to inpatient care (hemodynamic instability, ureteral obstruction, severe altered mental status perinephric or renal abscess, etc.)
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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

The patient is a male with a past medical history (PMH) of diabetes mellitus type 2 (DM2), alcohol abuse, cerebrovascular accident (CVA), and hypertension (HTN) who was admitted with complaints of (c/o) abdominal pain after a chair fell on him at home. The vital signs were notable for triage hypotension 68/45. The physical exam was notable for generalized abdominal tenderness and guarding, ecchymosis left eye (known injury). Lab work was notable for creatinine 3 (baseline 0.7), high anion gap metabolic acidosis (HAGMA), creatine phosphokinase (CPK) 850, lactate 3.6, and hyperkalemia. Imaging studies, a chest x-ray (CXR) and pelvic radiographs were within normal limits (WNL), computed tomography (CT) scan of the cervical/lumbar (C/L)-spine showed no acute osseous findings. The patient was diagnosed with acute kidney injury secondary to rhabdomyolysis and treated with intravenous fluids (IVF), Clinical Institute Withdrawal Assessment (CIWA), and physical therapy (PT) / occupational therapy (OT). The patient was discharged due to elopement. At issue is the medical necessity of an inpatient level of care.
The admission was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) abdominal pain after a chair fell on him at home The patient's lab work demonstrated acute kidney injury with a significant increase of creatinine, and this correlates to a drop in glomerular filtration rate (GFR) of approximately (~) 80 percent (%) from baseline, with concomitant electrolyte abnormalities, including hyperkalemia, as well as HAGMA and elevated lactate. He required close monitoring for adverse sequela such as electrolyte abnormalities and telemetry for arrhythmia monitoring, especially in light of triage hypotension and need to trend CPK. This patient suffered from severe acute kidney injury (AKI) and rhabdomyolysis, and the severity of these conditions indicates an observation level of care medically inappropriate to monitor and treat.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This adult male reportedly was admitted to inpatient hospital treatment due to falling and injuring self and he had alcohol withdrawal symptoms including tremors. He reportedly had falls and hurt his knee and also had arm pain, claudication, and change of gait. He reportedly had alcohol hepatitis, low potassium, and had reports of significant alcohol use with the last use the day prior to admission. He reportedly was assessed medically due to his falls, gait, and injuries, and also put on a Clinical Institute Withdrawal Assessment  (CIWA) protocol with Ativan and required and received Ativan. He reportedly was also given thiamine, folic acid,, and put on seizure precautions. 
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that he did not require inpatient acute hospital treatment, and they recommended a less restrictive level of care such as observational level of care.

The medical records provided enough specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. 

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

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

Diagnosis: Angioedema

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a patient that presented to the hospital complaining of lip swelling. The patient's past medical history was significant for ischemic heart disease and acute anterior wall myocardial infarction treated with primary angioplasty three days prior to presentation. The patient was discharged from the hospital earlier that same day on a regimen of losartan, spironolactone, ticagrelor, and statin therapy. The patient noted lip swelling and was instructed to return to the emergency department (ED) immediately. On arrival to the hospital vital signs were stable: blood pressure (BP) 158/109, pulse 84. Physical examination revealed swollen lips and uvula without tongue involvement. The patient was treated with intravenous steroids, famotidine, and diphenhydramine and was admitted to the hospital with a diagnosis of angioedema due to angiotensin receptor blocker treatment. Losartan was discontinued and the patient remained stable. The patient was discharged the following day.  

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. This patient noted lip swelling and had no compromise of the airway on physical exam. He was treated appropriately and monitored overnight.  Angiotensin receptor blockers such as losartan have been demonstrated to cause angioedema in up to 3.5% (percent) of individuals (Reference 1). In patients presenting with mild symptoms involving only the face and lips, four to six hours of observation is necessary to ensure no further progression.  When oropharyngeal structures are involved then additional observation is necessary (Reference 2). In this case the patient was appropriately observed overnight and responded to therapy. The patient was discharged the next day. Inpatient hospital admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back Pain
Treatment: intraosseous basivertebral nerve ablatio
The insurer denied intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient with complaints of low back pain. The pain involves the low back with radiation to the feet. He has tried medications including ibuprofen and Tylenol, and a Medrol Dosepak. He has tried physical therapy and chiropractic care. The physical examination notes facet loading, positive tenderness to extension and reverse straight leg raise is positive on the right. Magnetic resonance imaging (MRI) of the lumbar spine shows at lumbar (L) 3/4, there is a disc osteophyte complex. The suggested diagnosis is vertebrogenic pain. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

According to guidelines and cited references, despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. 
According to Becker, et.al : "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)." Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. As cited above, Becker. et.al trial indicated only a 17 patient observational study.
These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures.
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures.
Appeal type: Experimental/Investigational
Decision: Upheld

Orthopedic/Musculoskeletal
Pain Management

Diagnosis: Low back Pain
Treatment: intraosseous basivertebral nerve ablatio
The insurer denied intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient with complaints of low back pain which began approximately 4 months prior. The pain is rated 7-9 out of 10 and impacts activities of daily living. Prior treatments have included medications. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic changes at disc spaces lumbar (L) 3-4 and L4-5. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment intraosseous basivertebral nerve 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. There is a request 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.
Given the above, the proposed health service or treatment Intraosseous basivertebral nerve 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.  The denial is upheld.

The patient has a past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, and obesity. The patient presented to the hospital with complaints of pain and swelling of the left 3rd and 4th finger. 

Vitals on presentation included: Temperature 97.1 (degrees) Fahrenheit, Blood Pressure 153/80, Pulse 100, Respiratory Rate 20, oxygen (O2) saturation 95% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 14.6, hemoglobin (Hgb) 14.6, hematocrit (Hct) 42, creatinine 0.87, glucose 228, erythrocyte sedimentation rate (ESR) 14, and lactic acid 2.7.

The patient was started empirically on intravenous antibiotics (ceftriaxone) for cellulitis of left hand. X-rays of left hand showed no evidence of fracture or dislocation. The abscess was lanced with a syringe needle while in the emergency department. The patient remained afebrile, hemodynamically and clinically stable. The patient was discharged to continue oral antibiotics as an outpatient.       

According to documentation, patient presented with left hand/finger cellulitis. Otherwise, patient was afebrile and hemodynamically stable. Laboratory results were remarkable only for an isolated elevated WBC; x-rays were negative. Patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management only.

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 hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Congestion Syndrome
Treatment: Pelvic vein vascular embolization
The insurer denied Pelvic vein vascular embolization.
The determination is upheld.

This is a female patient who has pelvic pain and pressure refractory to non-steroidal anti-inflammatory drugs (NSAIDS), gabapentin, and pelvic floor exercise regimen. The patient states the dyspareunia and pelvic pain is disabling. She has had a prior hysterectomy and left oophorectomy. A computed tomography (CT) scan revealed dilated ovarian veins and parauterine veins. The provider wishes to perform pelvic vein embolization. This is under review.
The proposed health service or treatment pelvic vein vascular embolization 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 body of evidence in the peer-reviewed medical literature regarding embolization of the Ovarian Vein or Internal Iliac Veins for the treatment of pelvic congestion syndrome (PCS) is insufficient and poor quality. While some studies suggest favorable results of embolization for the treatment of pelvic congestion syndrome (PCS), additional well-designed randomized controlled trials are necessary to establish the relative safety and efficacy of the embolization procedure. A Hayes Health Technology Assessment (March 2020; updated March 2022) states there is a lack of robust evidence regarding the efficacy on the use of ovarian or internal iliac vein embolization for the treatment of PCS. The overall low quality of evidence primarily reflects individual study limitations, lack of comparison treatments, limited follow up, loss to follow-up and concerns regarding precision.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Congestion Syndrome
Treatment: Pelvic vein vascular embolization
The insurer denied Pelvic vein vascular embolization.
The determination is overturned.

This is a female patient with a history of pelvic pain with abdominal cramps that have been worsening over the last 5 years. Walking over time is very disabling for her and during the day, the pain is worse especially when standing. She has tried physical therapy with pelvic floor exercises that worsen her pain. Medications have been used. She has a pertinent diagnosis of pelvic venous abnormalities with a computed tomography (CT) scan. This issue is causing her problems with her quality of life as well. A physical examination confirms dyspareunia. She had an abdominal ultrasound as well.
Past medical records include evaluation by the other providers. Her history includes 4 deliveries and hysterectomy surgery and microhematuria. She had a recent cystoscopy and follows with gynecology. A repeat computed tomography (CT) venogram noted pelvic venous disorder. Treatment with medications had little effect. The current treatment plan is allowing the patient to undergo Pelvic Vein Vascular Embolization procedure. At issue is whether this is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes, the proposed health service or treatment Pelvic Vein Vascular Embolization, is likely to be more beneficial than any other standard treatment or treatments for the insured's life threatening or disabling condition or disease, namely symptomatic pelvic venous disease.
This condition is quite disabling for the patient and other options are not reasonable. Pelvic venous incompetence can be a disabling diagnosis and a medical problem that requires a meaningful treatment attempt. To treat the patient's condition by the performance of this minimally invasive approach, mainly venous embolization, will lessen her varicosities and improve her symptoms. Pelvic Vein Vascular Embolization is the only reasonable option for this patient and will give her the best chance for significant symptom relieve and obliteration/improvement of her pelvic venous abnormalities which are causing symptoms. Scholarly articles and scientific evidence in peer reviewed literature continue to show excellent results from pelvic vein embolization with great safety.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Congestion Syndrome
Treatment: Pelvic vein vascular embolization
The insurer denied Pelvic vein vascular embolization.
The determination is overturned.

This is a female patient with constant pressure that is 10 out of 10 (10/10) in intensity that is exacerbated by daily activities such as walking, standing and even prescribed pelvic floor exercises. She has debilitating dyspareunia and post coital pain. She has had a hysterectomy and left oophorectomy. Cross sectional imaging shows dilated parametrical veins. These symptoms and imaging findings are commonly seen with the described and established syndrome of pelvic congestion. At issue is whether the proposed health service or treatment pelvic vein vascular embolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The vascular embolization procedure is a well-established, highly effective treatment option for patients that have dilated pelvic congestion syndrome. The embolization procedure for this patient is the most appropriate and really the only available treatment option given her symptoms (pain) and imaging findings. This procedure is well described. Over the past two decades, there have been many papers that have been written on this procedure its application and effectiveness for this condition; this would confirm that this is an evidence-based treatment option that is the standard of care for this condition.