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

Diagnosis: Class II Division 1 malocclusion. 
Treatment: Braces. 
The insurer denied braces. 
The health plan's determination is overturned. 

The patient in question is a female with a Class II Division 1 malocclusion with maxillary and mandibular crowding. She has a severe overjet and appropriate overbite. She has lip incompetence at rest. She is treatment planned for braces to correct her malocclusion. 

Braces are medically necessary for this patient. This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. In her particular case, teeth 7-10 are proclined. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ millimeter (mm) overjets. The reference ruler is not visible on the cephalometric image, but the records provided support the assertion that her overjet is at least 6mm. For these reasons, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lewy Body dementia and blindness

Treatment: personal care aide (PCA) 7 days per week two 12 hour shifts per day (split shift) - 168 hours per week

The insurer denied coverage for personal care aide (PCA) 7 days per week two 12 hour shifts per day (split shift) - 168 hours per week

The denial is overturned


This is an elderly legally blind male with chronic medical problems including Lewy Body Dementia. He lives with his spouse who assists with medication and serves as a back-up caregiver. The insurer had approved personal care aide (PCA) 7 days per week, for 2 x 12 hour shifts. However, more recently the PCA services were reduced to 7 days per week live-in. The request is for resumption of the PCA 7 days per week, for 2 x 12 hour shifts, denied by the insurer. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as severely impaired. He is reportedly totally dependent for performing Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, and toilet transfer/use. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, eating, locomotion and ambulation. Limited assistance is reportedly needed for bed mobility. He is frequently incontinent of bladder and bowel. 

The patient's functional ability has significantly declined according to the two recent Uniform Assessment System (UAS) reports. Of particular note is the more recent decrease with personal hygiene, dressing, and mobility (locomotion and ambulation declined from supervision to extensive assistance). The patient's clinical condition and functional deficits are at a level and unpredictable as to require personal care aide (PCA) services 7 days per week, 24 hours per day (split shift). The provision of a live-in PCA may have been appropriate when the patient was at a higher functional level and had the informal assistance of his spouse. However, the patient's more recent functional decline, with associated severe cognitive deficits and vision impairment, supports the medical necessity of PCA 24 hours/day (split shift). In addition, a live-in PCA is unlikely capable of consistently obtaining approximately 5 hours of uninterrupted sleep. 

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 best interest of the patient. The medical necessity for personal care aide (PCA) 7 days per week two 12 hour shifts per day (split shift) - 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension, heart disease and atrial fibrillation

Treatment: increase Consumer Directed Personal Assistance Services to 70 hours per week

The insurer denied coverage for increase Consumer Directed Personal Assistance Services to 70 hours per week

The denial is upheld 


This is an elderly female with chronic medical problems including hypertension, heart disease and atrial fibrillation.  The patient lives alone in a private residence.  The insurer originally approved Consumer Directed Personal Assistance Services (CDPAS) 5 hours/day, 7 days/week for a total of 35 hours/week, followed by an increase to CDPAS 8 hours/day, 7 days/week for a total of 56 hours/week.  This request is for an increase in CDPAS to 10 hours/day, 7 days/week, for a total of 70 hours/week.  

In the Uniform Assessment System (UAS) report the patient's cognitive skills are described as "Modified independent."  The patient's ability to perform much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping; reportedly varies from extensive assistance to total dependence. 
 
The patient reportedly requires maximal assistance for bathing, upper body dressing (total dependence for lower body dressing), locomotion, toilet transfer/use and ambulation.  Extensive assistance is reportedly needed for bed mobility and limited assistance for eating.  She is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.  

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested Consumer Directed Personal Assistance Services (CDPAS) 70 hours/week.  Her ability to perform activities of daily living and self-sufficiency has reportedly declined and deteriorated, respectively over the prior 90 days and since a recent fall and hospitalization.  The patient reportedly fell on 1 occasion over the prior 30 days.  The patient's functional ability has declined when compared to the earlier UAS report.  Her cognitive status is much the same, which is contrary to the report in the later letter.  

This physician would agree the patient may benefit from additional monitoring for safety; particularly due to her reported weakness and falls risk.  However, Consumer Directed Personal Assistance Services (CDPAS) hours are approved primarily to provide hands on assistance for completion of IADL/ADL tasks when no else is available to provide assistance. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the already approved increase in CDPAS to 8 hours/day, 7 days/week for a total of 56 hours/week.  

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 an increase in Consumer Directed Personal Assistance Services to 70 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism spectrum disorder. 
Treatment: Personal Care Aide for 40 Hours Per Week. 
The insurer denied: Personal Care Aide for 40 Hours Per Week. 
The denial is upheld. 

The patient is a toddler female child with medical history significant for autism spectrum disorder. She is largely non-verbal, conveying needs through pantomime and caregiver anticipation. She is not yet potty-trained, and she wears diapers. She lacks safety awareness including elopement, has difficulty with self-soothing, and engages in repetitive actions like clapping and flicking fingers. She toe-walks and lines up objects. She has some oral sensory issues that can affect her food intake, and she requires supervision during eating because of behavioral problems. She requires assistance with all activities of daily living and is unable to complete any self-care activities independently. She has Brown syndrome, and her vision is being routinely monitored. The patient lives with her mother, her primary caregiver. Her father is not involved in her care. She also lives with her sister and her maternal grandmother, who assists in her care. She receives occupational therapy and speech therapy and has a referral for physical therapy when she starts school. 

The requested personal care aide services 40 hours/week are not medically necessary. 

This child with autism is fully dependent upon caregivers for all activities of daily living. At her current age, this is not significantly different from a neurotypical child of the same age and gender. However, she is essentially non-verbal, lacks all sense of safety awareness, and is an elopement risk. In general, she sleeps through the night and there are safety locks on doors to the outside and to the bathrooms. There are two caregivers in the home, her mother and her maternal grandmother. She has been approved for 5.25 hours/week personal care aide services. At her current age, based on the documentation provided, additional personal care aide services are not medically necessary. This will likely need to be revisited as she gets older, if she falls further behind neurotypical peers.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis.
Treatment: Copaxone.
The insurer denied Copaxone.  The denial is overturned.

The patient is an adult male with multiple sclerosis. He is currently on Copaxone (glatiramer acetate injection). The provider wishes to continue Copaxone. The request was previously denied coverage by the health plan, as the patient had not tried glatiramer acetate or Glatopa. The appeal letter notes that the patient has tried glatiramer acetate with side effects so severe that he had to stop working.

The requested Copaxone is medically necessary.

This is a continuation of Copaxone. The patient has been clinically stable and tolerates Copaxone. It has been documented that he has had an adverse reaction to glatiramer acetate. It has been noted that 45% (percent) of patients who were switched from Copaxone to glatiramer acetate had to switch back to Copaxone. Furthermore, the American Academy of Neurology (AAN) multiple sclerosis (MS) disease modifying therapy (DMT) guidelines recommend a disease modifying therapy switch only when one has a relapse, new magnetic resonance imaging lesions, or is intolerant of disease modifying therapy, none of which apply to this patient. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pulmonary embolism
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a female who initially presented with concerns for chest tightness and shortness of breath. Pertinent history included asthma. Initial vital signs revealed a temperature of 98.1oF, heart rate (HR) 98, blood pressure (BP) 124/80, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 100%. Initial laboratory testing revealed a white blood cell count (WBC) 9.4, Hemoglobin (HGB) 13.1, platelets (Plt) 201, blood urea nitrogen (BUN) 9, Cr 0.82, international normalized ratio (INR) 1.0, and Troponin 0.01. An electrocardiogram (EKG) was unremarkable. A computed tomography angiography (CTA) chest revealed multiple bilateral lobar, segmental, and subsegmental pulmonary emboli as well as straightening of the interventricular septum suggestive of right heart strain. 

The inpatient hospital admission was medically necessary. The patient had a history of asthma who presented with concerns for chest discomfort and shortness of breath. Initial evaluation revealed tachycardia and computed tomography (CT) evidence of bilateral pulmonary emboli with concerns for right ventricular strain. Therapeutic anticoagulation was initiated via a heparin infusion and further diagnostic testing was pursued. Cardiology consulted, documented a pulmonary embolism simplified index of 1, and did not recommend thrombectomy following a relatively unremarkable echocardiogram. With continued treatment, tachycardia resolved, presenting symptoms improved, and the patient was discharged on an oral anticoagulant. Moreover, clinical indications for admission to inpatient care were met. The patient had a vital sign abnormality (tachycardia) and concerns for right ventricular dysfunction or strain via initial CT angiogram. An inpatient stay was indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left tibia fracture status-post Open Reduction Internal Fixation (ORIF)
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient had a left tibia fracture and procedure. There were no postoperative surgical complications of hemodynamic instability, infection, or persistent pain. 

Labs revealed persistent hyperglycemia. The patient underwent an intramedullary nailing of a left tibia fracture. The patient was transferred to the Post Anesthesia Care Unit (PACU) after surgery. Physical therapy (PT) noted dizziness and orthostatic hypotension. The patient continued to receive close postoperative monitoring. 

The medical records support the level of care provided. The patient had unstable diabetes. The patient's elevated blood sugar required stabilization prior to surgery. The procedure would not be performed until correction. Simply stated an increased chance of complication could result. Orthopedic and Anesthesia Guidelines do not support semi emergent surgery with hyperglycemia. 

The records also showed the episode of hypotension and tachycardia. This would limit the patient's ability to be mobilized. The records also showed ongoing need for intravenous (IV) pain medication. The combination of persistent elevated blood sugars, need for pain medication, tachycardia and hypotension substantiate the need of acute level services.

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 best interest of the patient. The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with no significant past medical history. His presenting complaints were dyspnea and wheezing. The physical exam was notable for wheezing and coarse breath sounds. Lab results were unremarkable. Radiology was notable for a chest x-ray without acute abnormalities. In the emergency department (ED), he was treated with steroids and duonebs with partial improvement, and was admitted to an inpatient level of care for further evaluation of dyspnea and wheezing. At issue is the medical necessity of an inpatient stay.
The inpatient hospital stay is not medically necessary.
The patient presented with mild respiratory complaints likely secondary to a new diagnosis of asthma or reactive airway disease. He demonstrated symptomatic improvement with initial therapies in the ED. The patient did not demonstrate concerning signs or symptoms such as hypoxia, respiratory distress, or hemodynamic instability, nor did he have any comorbidities that would make his presentation higher risk. A lower level of care would have been appropriate to monitor the patient and continue initial therapies, with transition to outpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild thrombocytosis
Treatment: Gene Panel testing
The insurer denied Gene Panel testing.
The determination is upheld.

This is a female patient with a mild thrombocytosis. The patient's complete blood count is otherwise unremarkable. The patient has no other medical problems but is noted to be iron deficient with a ferritin of 30. A myeloproliferative panel (LeukoVantage) was obtained; this is under review for medical necessity.
This patient had a mild thrombocytosis without clinical or laboratory findings consistent with a myeloproliferative disorder. Further, this patient had findings that could explain her thrombocytosis (i.e. iron deficiency). The panel obtained included 26 genes, the majority of which lack data in the evaluation of a myeloproliferative disorder. Support for this panel is not present in the National Comprehensive Cancer Network (NCCN) Guidelines nor in the peer-reviewed literature. As the results of this panel have not been demonstrated to improve outcomes nor to guide management/diagnosis, it is also not recommended by the authors of UpToDate. For these reasons, medical necessity cannot be established for this service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Intraosseous ablation of the basivertebral nerve. 
The insurer denied Intraosseous ablation of the basivertebral nerve. 
The determination is upheld. 

This is a patient with a past medical history (PMH) of lower back pain (LBP) over the past 3 years. She has trialed acupuncture, chiropractic, physical therapy (PT) greater than (>) 6 weeks, medications and home exercises. Her pain ranges from a 5-10/10 on the Visual Analog Scale (VAS). At times, the pain radiates to her left lower extremity (LLE). Per report, her pain impacts her activities of daily living (ADLs), including sleep, chores, work and leisure activities. She has tried cyclobenzaprine, gabapentin and tizanidine. Her physical exam is notable for lumbosacral tenderness and positive (+) straight leg raise (SLR) on the left (L). She had a magnetic resonance imaging (MRI) scan. There is end plate edema at lumbar (L) 2-3 which is likely a sequelae of degenerative disc disease (DDD) rather than an infectious process per radiology read. She also has multilevel DDD with mild neuroforaminal (NF) stenosis bilaterally from lumbar (L) 2-5. Intraosseous ablation of the basivertebral nerve is under review. 

It is unlikely that the proposed treatment will be more beneficial than standard treatment. There is no evidence of trials of less invasive standard options including oral nonsteroidal anti-inflammatory drugs (NSAIDS) or interventions such as lumbar epidural steroid injections or medial branch block/radiofrequency ablation. There is not a recent erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) as suggested by the radiologist to rule out an infectious process. Additionally, on examination, it appears she has diffuse axial lumbar pain as well as left lower extremity (LLE) radicular pain. This reviewer also looked for evidence of more specific examination findings to support the L2-3 region may be the pain generator versus (vs) the lower lumbar spine.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Intraosseous ablation of the basivertebral nerve. 
The insurer denied Intraosseous ablation of the basivertebral nerve. 
The determination is upheld. 

This is a female patient with complaints of chronic low back pain. She has undergone prior treatments, including acupuncture, chiropractic care, home exercises, medications, as well as physical therapy. The pain severely impacts activities of daily living (ADLs). The pain ranges from 5-10 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine reported Modic type II changes. At issue is whether the proposed health service or treatment Intraosseous ablation of the basivertebral nerve 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 ablation of the basivertebral nerve 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 ablation of the basivertebral nerve 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: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Intraosseous ablation of the basivertebral nerve. 
The insurer denied Intraosseous ablation of the basivertebral nerve. 
The determination is upheld. 

This is a patient diagnosed with low back pain. Records submitted show that the patient was recommended to undergo the Intracept procedure (interosseous basivertebral nerve ablation), which was denied by the health plan. The provider notes the patient has a history of low back pain that began several years ago and has tried multiple treatments including acupuncture, chiropractic, heat, ice, home exercise, medication management and physical therapy. Medications have included Ambien, cyclobenzaprine, gabapentin and tizanidine. The pain ranges from 5-10/10 and is impacting activities of daily living. The provider reports the patient had magnetic resonance imaging (MRI) showing Modic type II changes at the lumbar (L)3 disc space and believes that this is the source of the patient's chronic back pain. 
The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation (BVN) 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 the patient was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). There are 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 the safety and efficacy. This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.