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

Diagnosis: Stage 4 Pressure Ulcer
Treatment: Personal care aide (PCA) 2 12-hour split shifts per day, 7 days a week
The insurer denied the Personal care aide (PCA) 2 12-hour split shifts per day, 7 days a week.
The determination is overturned.

The patient has a medical history notable for a stage 4 pressure ulcer of the sacral region. The patient is currently approved for 12 hours per day, 7 days per week (84 hours per week) of personal care services. The patient and her care team requested an increase to 2-12 hours per day (split shift), 7 days per week (168 hours per week), and this request was denied by the health plan.
A letter of support for this appeal was provided by a patient advocate. The letter states that the patient is bed bound and cannot change her diaper with fecal incontinence. She is dealing with stage 2 and stage 4 pressure ulcers that are not yet healed, and had to undergo debridement recently.
A letter of support for this appeal was provided by a treating physician. The letter states that the patient was hospitalized and has been deteriorating from a functional standpoint. She is "unable to ambulate, requires a wheelchair for mobility and assistance with transfers."
A Uniform Assessment System (UAS) was completed  and was available for review. Cognition was minimally impaired; patient was alert and oriented times three with some forgetfulness noted. She is able to direct her own care. For her instrumental activities of daily living (IADL), she requires total dependence for meal preparation, housework, stairs, and shopping. She requires maximal assistance for transportation and extensive assistance for managing medications. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is incontinent of urine with no control present and is occasionally incontinent of stool. She has an indwelling Foley catheter since her recent treatment of stage 4 pressure ulcer with debridement.
At issue is the medical necessity of personal care aide (PCA) 2 12-hour split shifts per day, 7 days a week.

The requested health service of personal care aide (PCA) 2 12-hour split shifts per day, 7 days a week is medically necessary for this patient.
The patient already has pressure ulcers of various stages on the sacrum which recently required surgery. The patient requires hands on assistance for all ADLs and IADLs, including turning and positioning in bed. She will need turning and repositioning every 2-3 hours throughout the day and night to promote healing of her wounds. Furthermore, she needs prompt diaper changes and incontinence care to prevent further skin breakdown and contamination of her wounds. Failure to provide support for these personal care needs would likely result in worsening of her health conditions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied: Wegovy
The denial is: Overturned

The patient is a female requesting treatment with Wegovy for her weight. This patient has a body mass index (BMI) of 28. She has dyslipidemia but is not diabetic. She has cirrhosis due to non-alcoholic steatohepatitis (NASH). The attending gastroenterologist would like to use Wegovy in this patient. The subject under review is the medical necessity for Wegovy in this case.

Yes the requested treatment with Wegovy is medically necessary for this patient.
The plan alternatives: Ozempic, Victoza, Trulicity, are Food and Drug Administration (FDA) approved to treat diabetes and not FDA approved to treat obesity or overweight with a weight related condition.
The Food and Drug Administration approved Wegovy (semaglutide) injection (2.4 milligrams [mg] once weekly) for chronic weight management in adults with obesity or overweight with at least one weight-related condition (such as high blood pressure, type 2 diabetes, or high cholesterol), for use in addition to a reduced calorie diet and increased physical activity. Wegovy is indicated for chronic weight management in patients with a body mass index (BMI) of 27 kilograms per square meter (kg/m2) or greater who have at least one weight-related ailment or in patients with a BMI of 30 kg/m2 or greater. Being obese or overweight is a serious health issue associated with some leading causes of death, including heart disease, stroke and diabetes, and is linked to an increased risk of certain types of cancer. Losing 5%(percent) to 10% of body weight through diet and exercise has been associated with a reduced risk of cardiovascular disease in adult patients with obesity or overweight. Wegovy works by mimicking a hormone called glucagon-like peptide-1 (GLP-1) that targets areas of the brain that regulate appetite and food intake. The medication dose must be increased gradually over 16 to 20 weeks to 2.4 mg once weekly to reduce gastrointestinal side effects.
The most common side effects of Wegovy include nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, eructation, hypoglycemia in patients with type 2 diabetes, flatulence, gastroenteritis and gastroesophageal reflux disease.
The use of Wegovy to treat this patient who is overweight and has dyslipidemia is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular Tachycardia (SVT)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a male who was brought into the hospital via ambulance for complaints of feeling unwell; he was found pale and diaphoretic when Emergency Medical Services (EMS) arrived, found him tachycardic in the 170s, diagnosed with supraventricular tachycardia (SVT), and cardioverted with 150 Joules (J) shock. Blood pressure reportedly ran low, and the patient was resuscitated with 1 liter (L) of saline. After the shock delivery, the patient reverted to normal sinus rhythm. Subsequent vital signs appeared stable, with systolic blood pressure in the 100s. His breathing was unlabored, and he did not appear to be in additional distress after the cardioversion. The patient has a history of congestive heart failure, diabetes, and possible atrial fibrillation. He is chronically on carvedilol and Eliquis. The patient has experienced palpitations for the past week, with associated lightheadedness. He had a normal stress test the previous month.
The cardiologist assessed the patient and recommended a follow-up with his outpatient cardiologist in 2 to 3 weeks. They recommended the continuation of Eliquis and Coreg. They recommended decreasing the dose of Entresto and spironolactone.
The subject under review is the medical necessity for the inpatient hospital admission.

The inpatient hospital admission is not medically necessary for this patient. The patient experienced supraventricular tachycardia, which resolved after direct cardioversion with 150 J by EMS. He was initially hypotensive, with stabilization of the blood pressure after cardioversion and infusion of 1 L of crystalloid solution. There were no repeat efforts at cardioversion and no recurrent cardiac arrhythmias on telemetry monitoring during the hospital stay. The patient is already anticoagulated chronically. There was no further hemodynamic instability. There was no evidence of an acute myocardial infarction causing the patient's symptoms. There was no worsening of the underlying heart failure symptoms. Additionally, the patient rapidly improved. The electrolytes and the renal function rapidly returned to baseline within 24 hours. There was no indication for renal replacement therapy.
In conclusion, the patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia. 
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day-7 days per week; 12 hours per day - 7 days per week (split shift) a total of 168 hours per week. 

The insurer denied: Personal Care Aide (PCA) Level 2: 12 hours per day-7 days per week; 12 hours per day - 7 days per week (split shift) a total of 168 hours per week.
The denial is overturned. 

This is a case review for a female with medical history notable for end-stage Alzheimer's dementia and incontinence of urine/stool. The patient is currently approved for 24 hours per day, 7 days per week (live-in) of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split shift), 7 days per week (168 hours per week), the medical necessity for this is the subject under review.

The requested health service of Personal Care Aide (PCA) Level 2: 12 hours per day-7 days per week; 12 hours per day - 7 days per week (split shift) a total of 168 hours per week is medically necessary for this patient. 

The patient is approved for 24-hour live-in personal care, which requires that the aide get an 8-hour rest period each night (with a minimum of 5 hours of uninterrupted rest). If the patient has care needs that would preclude this sleep window, then split-shift care is medically necessary. 

The patient has end-stage dementia on hospice care. She is totally dependent for every Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). She is incontinent of urine and stool with no control present. The patient requires diaper changes and turning/repositioning in bed; she will therefore have personal care needs every 2-3 hours throughout the day and night. Live-in care is insufficient for the patient and split-shift continuous care is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve Treatment in the Spine
The insurer denied: Nerve Treatment in the Spine
The denial is upheld

The patient is an adult male with low back and left knee pain. The patient had 50% (percent) relief with L5/S1 (lumbar five/sacral one) discogram. The patient's pain medications include cyclobenzaprine, diclofenac, meloxicam, methocarbamol, and Medrol dose pack. MRI (magnetic resonance imaging) of the lumbar spine shows worsening of mild/moderate right foraminal stenosis at L5-S1 (lumbar five/sacral one), decrease in left paracentral disc protrusion, as well as lower lumbar scoliosis and varying degrees of lumbar foraminal stenosis and disc bulge without significant central stenosis.
The request for L5/S1 (lumbar five/sacral one) Intracept procedure was denied coverage by the health plan, as not enough evidence has been shown for this procedure to be effective, and it was therefore determined to be not medically necessary. This denial is being appealed.

The requested Nerve Treatment in the Spine is not medically necessary.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.
At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a female patient with a history of end stage renal disease, (ESRD) on hemodialysis, who presented to the hospital with epigastric pain associated with dyspnea. She had no fevers, chills nausea, or vomiting. Her vital signs showed that she was initially afebrile with a blood pressure of 198/77, a pulse of 61, a respiratory rate of 22 and a room air pulse oximetry of 100 percent (%). On exam, she appeared anxious and uncomfortable.
 An electrocardiogram (EKG) showed atrial fibrillation without ischemic changes. A chest x-ray was unremarkable. A right upper quadrant ultrasound (US) showed a 3 millimeter (mm) echogenic focus in the region of the common bile duct but negative for biliary obstruction. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary based on the documentation provided.
The patient received intravenous (IV) bicarbonate, insulin, calcium gluconate and Lokelma. Nephrology was consulted for dialysis needs. Gastroenterology was consulted and recommended a magnetic resonance cholangiopancreatography (MRCP). The MRCP did not indicate a filling defect within the common bile duct. Her symptoms improved with dialysis and did her potassium level. Gastroenterology (GI) recommended weekly monitoring of her liver function tests and outpatient follow up if needed. She was also noted to have pancytopenia during her stay and both oncology and infectious disease were consulted. Infectious disease did not feel that she had an infection. Oncology felt her leukopenia and thrombocytopenia were likely chronic and due to splenomegaly. Oncology recommended outpatient follow with GI to assess for cirrhosis and check a Fibro-scan. She was stable for discharge.
This patient presented with epigastric abdominal pain. She was hemodynamically stable. She did not have cardiac arrhythmia of immediate concern. She did not have severe electrolyte or metabolic abnormalities. Her potassium was elevated but she did not have EKG changes. She did not have uremic finding that were severe or persistent. She was not in respiratory distress. She did not have a documented infection that required inpatient care. She did not have signs of acute cholangitis, acute cholecystitis or obstruction of gallbladder or common bile duct. There were no other clinical finding that required inpatient management or monitoring.
Appeal type: Experimental/Investigational
Decision: Upheld

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

The patient is a male with chronic lower back pain (LBP) causing significant impact on his activities of daily living (ADL), including sleeping. The patient rates his pain on Visual Analog Scale (VAS) on average 8-9/10. The pain is axial midline LBP that is exacerbated by flexion or lifting. It is improved with extension or laying flat. It has been progressive but there are no radicular or myelopathic symptoms. He has received multiple interventions since 2015 including epidural steroid injections and one sacroiliac injection although his response was not detailed. He has also used over-the-counter (OTC) medications, non-steroidal anti-inflammatory drugs (NSAIDs), hydrocodone, home exercise, chiropractic treatment, and physical therapy (PT). 

The Intracept Procedure (Radiofrequency Ablation of Nerves) 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 limitations due to his chronic lower back pain (LBP) and he is presumably taking opioids to manage the pain. The requesting physician notes that the patient's pain is significant and limits activities of daily living (ADL) but there is no ODI (Oswestry Disability Index) score. Additionally, the magnetic resonance imaging (MRI) report does not detail the types of Modic changes and STIR (Short TI inversion-recovery) imaging is not included. The pain physician noted that the radiologist diagnosed end plate Modic 1 and 2 changes but this is not in the radiology report and the marrow findings (signal intensities) are not entirely consistent with these changes. It is difficult to determine with the information presented if this patient meets the criteria demonstrated in studies that predict he will benefit from the procedure. Due to the lack of substantiating evidence, the Intracept procedure is not likely to be more beneficial than standard treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

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

The patient is a male with complaints of chronic low back pain. He has tried medications, home exercises, as well as low back injections. The pain continues to interfere with ADL (activities of daily living). He has also undergone chiropractic care as well as activity modification. There is a request for Intracept Procedure (Radiofrequency Ablation of Nerves).

The proposed Intracept Procedure (Radiofrequency Ablation of Nerves) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
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: Intracept Procedure
The insurer denied the Intracept Procedure. The health plan's determination is overturned.

This is a male who has chronic back pain. His pain is predominantly in the back across his lower lumbar region with no radicular symptoms. Pain level is 8-9/10. He is unable to work due to this pain. He underwent multiple epidural injections without improvement. Other treatments including physical therapy (PT), chiropractic manipulation and non-steroidal anti-inflammatory drugs (NSAIDs) had failed to provide him with adequate pain relief. 

The Intracept Procedure (Radiofrequency Ablation of Nerves) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intraosseous nerve ablation procedure (INTRACEPT) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. His pain is severe enough to have a negative impact on his activities of daily living (ADL), and he is unable to work due to severe pain. He had tried physical therapy (PT), chiropractic manipulation, non-steroidal anti-inflammatory drugs (NSAIDs) and epidural injections without improvement. Further interventions are medically necessary to improve his pain and function. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] 

This patient presented to the emergency department with a two-day history of right upper quadrant abdominal pain. Vital signs were within normal limits. Aspartate aminotransferase (AST) and alanine transaminase (ALT) were elevated at 456 and 473, respectively. White blood cell count was 8.2. An abdominal ultrasound demonstrated findings consistent with acute cholecystitis and dilation of the common bile duct up to 7 millimeters (mm). A magnetic resonance cholangio pancreatography (MRCP) of the abdomen was performed that demonstrated acute cholecystitis with no evidence of choledocholithiasis. 

The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. On postoperative day one, the patient was noted to have a syncopal episode. On postoperative day two, the patient still reported dizziness that resolved with intravenous fluids. The patient was discharged. 

Per Milliman Care Guidelines (MCG) criteria, admission is necessary for acute cholangitis, acute cholecystitis, or calculus or obstruction of the gallbladder or bile duct. According to clinical documentation, the patient met criteria for acute cholangitis because the ALT was greater than 1.5 times the upper limits of normal.

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 the inpatient admission is substantiated.