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

Diagnosis: Thoracic (T) 6 complete paraplegia due to spinal cord injury
Treatment: Custom visco seat for the commode (E1399 x 2)
The insurer denied coverage for custom visco seat for the commode (E1399 x 2)
The denial is overturned.

This is a patient with thoracic (T) 6 complete paraplegia due to spinal cord injury.

The patient has autonomic dysreflexia, neuropathic pain on medications, bladder and bowel incontinency, pre-symptomatic Huntington disease. The patient lost 100 pounds since the date of injury due to a motor vehicle collision (MVC), his shower/commode wheelchair that he has is too large for him, and visco seat foam was requested through patients care providers and with physical therapy recommendations to prevent a pressure ulcer, as patient is wheelchair bound for rest of his life. The patient is pretty active and works full time. 

A physical therapy (PT) notes explained why patient needs different visco seat foam for commode, which he already had but worn out, and it explained patient already has gluteal pressure sore. 

"Managing decubitus ulcers is complicated as there is no fixed treatment regime or algorithm. Once it has developed, there should be no delay in treatment, and management should start immediately. Treatment varies between site, stage, and associated complications of the ulcer. The goal of all the various treatment options is to; minimize the pressure exerted on the ulcer, minimize contact of the ulcer with a hard surface, decrease moisture, and to keep it as aseptic or least septic as possible. The choice of treatment options should be according to the stage/grade of the ulcer, and what the purpose of the treatment should be (decreasing moisture, removal of necrotic tissue, controlling bacteremia).  Prevention is clearly the best treatment with excellent skincare, pressure dispersion cushions, and support surfaces. Support surfaces decrease the amount of pressure on the wound. Support surfaces can be either static (e.g., air, foam, and water mattress overlays) or dynamic (e.g., alternating air overlay)." (Zaidi, S., & Sharma, S. 2022).

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient, as the request was medically necessary. 

This patient will definitely benefit from the visco seat for commode. This is not a matter of comfort or convenience or cosmetic, but a medical necessity.      

This patient is T6 spinal cord injury, paraplegic, with neurogenic bowel and bladder, neuropathic pain, and pressure wound, who had lost 100 pounds (lbs) since the injury. He appears to be pretty active. Given the patient's weight loss and pressure wound formation over the gluteal area, the requested visco seat for commode is deemed to be medical necessity.

Based on the above, the insurer's denial must be overturned. The medical necessity for custom visco seat for the commode (E1399 x 2) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: back pain
Treatment: pain management
The insurer denied Pain Management Injections in Spine. The health plan's determination is overturned. 

The patient is a male with a past medical history (PMH) of lumbar herniation of the nucleus pulposus (HNP) who presented with recurrent back pain and left lower extremity (LLE) pain. 

Pain Management Injections in Spine are medically necessary and within the standard of care for this patient. 

The patient had 80% (percent) relief of pain and improvement in function (walking) > (greater than) 2 months.
He had an magnetic resonance imaging (MRI) which was notable for levoscoliosis, L3-4 disc bulge with mild compression of L (left) L3 root, small L4-5 herniation with mild thecal sac compression and small L foraminal disc herniation at L5-S1 causing mild to moderate compression of the exiting L L5 root and mild R (right) foraminal narrowing.
Epidural steroid injection for this patient given his recurrent symptoms, prior positive response to his last epidural and concordant findings on lumbar magnetic resonance imaging (MRI) are indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Varicosities
Treatment: Gonadal Vein Embolization
The insurer denied: Gonadal Vein Embolization
The denial is: Overturned

The patient is a female that has a history of pelvic pain, heaviness and "pulling" sensation that has been refractory to oral contraceptive pills, and intrauterine device (IUD). She is now limited in her ability to stand. The pain also affects her while sitting. magnetic resonance imaging (MRI) performed several months prior to appeal shows prominent vessels in the region of the uterus adnexa, specifically the ovarian and uterine vessels. The provider has proposed gonadal vein embolization, which is the subject under review.

The health plan's determination is overturned.

The proposed gonadal vein embolization is likely to be more beneficial for this patient than any standard treatment. The patient was referred to the Interventional Radiologist after other treatments for her pelvic pain had failed. Gonadal vein embolization is a safe and effective procedure. The patient has a history and almost more importantly, imaging that confirmed the diagnosis of pelvic venous incompetence (also known as [AKA] pelvic congestion syndrome).
The patient's clinical symptoms and imaging findings would suggest endovascular therapy (in this case gonadal vein embolization) which is a safe option to treat patients with recalcitrant, non-cyclic pelvic pain, particularly in patients where cross sectional imaging suggests the presence of pelvic congestion syndrome.
This treatment will be more beneficial for the patient than standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Varicosities
Treatment: Gonadal Vein Embolization
The insurer denied: Gonadal Vein Embolization
The denial is: Upheld

The patient is a female with chronic pelvic pain and heaviness despite hormonal therapy and lidocaine cream. Computed tomography (CT) venogram performed demonstrated prominent left pelvic veins and a prominent left gonadal vein. Magnetic resonance imaging (MRI) demonstrated prominent myometrial vessels and no evidence of endometriosis. The interventional radiology (IR) provider wishes to perform gonadal vein embolization, which has been denied by the patient's health plan. The subject under review is whether the requested procedure is likely to benefit this patient more than standard treatment. 

The health plan's determination is upheld.

The proposed gonadal vein embolization is not likely to be more beneficial for this patient than standard treatment. There is a lack of peer-reviewed literature supporting a better long-term clinical outcome with pelvic vein embolization compared to standard medical treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic Varicosities
Treatment: Gonadal Vein Embolization
The insurer denied: Gonadal Vein Embolization
The denial is: Overturned

The patient is a female with history of symptomatic pelvic varicosities. The patient cannot work and has been declared disabled. She has vaginal and pelvic pain, and bladder symptoms.
Magnetic resonance imaging (MRI) and ultrasound note engorged pelvic varicosities and enlarged ovarian/gonadal veins. Computed tomography (CT) venogram confirms.
Past medical history reviewed. She has had a trial of progesterone/oral contraceptive pills (OCP) and use of topical analgesic medications. She has a history of intrauterine device (IUD) for contraception. Her pertinent past medical records reviewed, including past surgical history, medications, and lab work.
She needs a gonadal vein embolization performed. The current treatment plan is for performance of the procedure, which is minimally invasive.
The subject under review is whether the requested gonadal vein embolization is likely to be more beneficial for this patient than any standard treatment.

The proposed procedure, gonadal vein embolization, is likely to be more beneficial than any standard treatment or treatments, for the patient's disabling condition. The procedure is medically appropriate to treat this patient's condition and is not experimental nor investigational. The proposed treatment, based on present scientific data, has been proven to be safe and effective. Scholarly articles and scientific evidence in peer review literature continue to show excellent results from gonadal vein embolization with great safety.
This patient's pelvic varicosities should be treated. The patient is young, and this condition is quite disabling for her, and other options are not reasonable. Other therapies have already been tried leaving gonadal vein embolization as the best next alternative. The minimally invasive procedure would be a low risk with high expected success and with few complications and would be reasonable and be part of a meaningful treatment.
Gonadal vein embolization is the only reasonable option for this patient and will give her the best chance for significant symptom relief and obliteration of her pelvic varicosities.
The alternatives of surgery or medication are generally not as efficacious as an embolization procedure with venogram.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, diabetes, hypothyroidism, polyarthritis, and autoimmune hepatitis 
Treatment: Increase personal care aide (PCA) to 50 hours/week (consumer direct, one client)
The insurer denied an increase in PCA to 50 hours/week (consumer direct, one client).
The denial is upheld.

The patient is an elderly female with past medical history of hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, diabetes, hypothyroidism, polyarthritis, and autoimmune hepatitis who also had an episode of COVID-19 (Coronavirus 2019) infection and has deconditioning. She lives with her daughter. The patient is requesting an increase in home care services. This review is for an increase in personal care aide (PCA) to 50 hours/week (consumer direct, one client).

The proposed treatment is not medically necessary.

This patient has multiple co-morbidities but is able to ambulate with assistance. She is able to feed herself once items are placed within her reach. She is able to reposition herself in bed. She has occasional urinary incontinence. She did not have any falls in the last 90 days. There is no progressive neurologic condition. The patient lives with her daughter. Monitoring and supervision will not qualify for increase in personal care hours. The health plan approved 40 hours/week are appropriate. There is not medical necessity for additional hours at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Class III skeletal occlusion, crossbite.
Treatment:  D8080 Braces and D8670 Monthly Visits.

The insurer denied the D8080 braces and D8670 monthly visits.  The denial is overturned.

The patient is an adult female requesting orthodontic benefits. The patient has a Class III skeletal occlusion with mild upper and lower crowding. Her mandibular canines are in crossbite as is the left posterior quadrant.

The proposed treatment is medically necessary.

The patient has two lower anterior teeth in crossbite (reverse bite). There is attachment loss at the gingival margins. These are two automatic qualifiers for orthodontic benefits according to the handicapping scale. Orthodontic treatment is needed to correct these problems, and the monthly visits are to follow up and make sure the treatment is effective.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leiomyoma.
Treatment: Full Hospital Admission.

The insurer denied coverage for the full hospital admission.  The denial is overturned.

The patient is a female with a history of symptomatic uterine fibroids. She presented to the hospital and underwent an open abdominal myomectomy. The hospital course was uneventful. The patient was discharged after a period of medical stability. 

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. 

On postoperative day 2, if the patient is passing flatus and tolerating regular diet, the patient is discharged home. This patient was managed according to the guidelines and the standard of care and the admission was medically necessary. Milliman Care Guidelines (MCG) Laparotomy Guidelines were met for this patient.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Suicidal ideation.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The case involves a young adult male, who presented to the emergency department brought in by emergency medical services with drug-induced dystonia in the context of a suicide attempt with an overdose of risperidone. The patient had awakened feeling sad and took 25 milligrams (mg) of risperidone with subsequent onset of locked jaw and head twisting and jaw clinching. He was treated in the emergency department with intravenous (IV) Benadryl, intramuscular (IM) benztropine and Ativan, and admitted to acute inpatient level services with 1:1 monitoring and continued supportive measures, as well as use of benztropine 2 mg three times a day.

Inpatient hospital services are medically necessary for this patient.

The patient's symptoms of a mood disturbance and psychotic disorder together with the complications of the overdose with a dystonia and continued risk for suicidal or self-harming behavior warranted the admission and the continued acute inpatient level structure and monitoring through discharge. These clinical factors support the medical necessity for the admission to inpatient level structure and 24-hour safety monitoring with continued treatment of the drug-induced dystonia and effort to obtain psychiatric consultation and achieve a safe and clinically appropriate discharge and disposition.
The patient required the admission and the continued acute inpatient level care and the structure and the monitoring of an acute inpatient level setting in order to remain safe and to administer treatment for his general medical and psychiatric disturbance and co-occurring substance use disorder while conducting an evaluation, and while observing his functioning with the resumption/adjustment of clinically appropriate medication. The clinical course was complicated by the overdose and suicidality and by substance use disorder with cannabis (marijuana). Additionally, the treatment team was planning for a safe and clinically appropriate disposition with aftercare arrangements.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atypical Chest Pain.
Treatment:  Inpatient Hospital Admission.

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

This is an adult male, who presented to the hospital complaining of chest pain over a six-day period. Pain was exacerbated by movement of both arms. The patient had no significant past medical history. Upon arrival to the hospital, vital signs were stable (blood pressure [BP] 159/90, Pulse 50 beats per minutes [bpm]). Physical examination was within normal limits. A 12-lead electrocardiogram (EKG) revealed sinus bradycardia at 50 bpm, normal axis and no ischemic ST (interval on EKG) or T (interval on EKG) wave changes. Serum blood testing was significant for an elevated high sensitivity troponin (110ng/L [nanograms per liter] and 111) and an elevated creatinine (CR)-1.3 mg/dl (milligrams per deciliter). The unchanged troponin levels do not represent an acute event. The patient was admitted to the hospital for further testing and treatment. Echocardiogram revealed a preserved left ejection fraction (LVEF) (60-65% [percent]) without any wall motion abnormalities. The patient was discharged the day after presentation.

This patient presented with atypical chest pain and no significant past medical history. His pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (history, EKG, age, risk factors, and troponin) score, he was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care. Based on the above, the insurer's denial must be upheld. 

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital admission for the date of service is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper abdominal pain, nausea, and vomiting.
Treatment: Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission.  The denial is upheld.

The patient is an adult male with a BMI (body mass index) of 38. He presented to the ED (emergency department) with new onset right upper abdominal pain, nausea, and vomiting of 2-days duration.

At the time of presentation, the patient was without fever and vital signs were normal. He was tender in the right upper quadrant. The WBC (white blood cell) count was elevated at 15.4 K (thousand). The complete metabolic panel identified normal liver enzymes and bilirubin. Abdominal ultrasound showed gallstones within the gallbladder, with gallbladder wall thickening. He was admitted to the hospital.

The patient was evaluated with surgery consultation. The patient underwent laparoscopic cholecystectomy. The operation was performed without complication, though a drain was placed due to the degree of inflammation and findings of acute gangrenous cholecystitis. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting the next day with planned short-term follow up.

The inpatient hospital admission was not medically necessary.

An inpatient level of care was not medically necessary in this case. This patient is an adult male who presented to the hospital with abdominal pain. It was determined that he had cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established. The patient was admitted to the hospital. He underwent surgery to remove the gallbladder. The patient responded favorably to treatment and was stable for discharge from the hospital the day after with planned follow up. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, surgical assessment and monitoring, laparoscopic cholecystectomy as performed, provision of IV (intravenous) antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes and dementia
Treatment: 7 days per week, 12 hours per day for a total of 84 hours per week of Personal Care Worker (PCW) services
The insurer denied coverage for 7 days per week, 12 hours per day for a total of 84 hours per week of Personal Care Worker (PCW) services.
The denial is overturned.

This is an elderly patient with multiple medical problems including hypertension, diabetes and dementia. She lives with her son in a 3-bedroom apartment. She is currently approved for Personal Care Worker (PCW) services 7 hours/day, 7 days/week for a total of 49 hours/week and is requesting an increase to 12 hours/day, 7 days/week totaling 84 hours per week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." She requires maximal assistance for bathing, lower body dressing, ambulation and toilet transfer. Extensive assistance is required for personal hygiene, upper body dressing, bed mobility, eating and toilet use. She is frequently bladder incontinent and infrequently bowel incontinent. There has been a functional decline compared UAS report; particularly for bed mobility, eating, ambulation and toilet transfers. She is also provided informal assistance by her son who is no longer able to provide such assistance due to employment. The combination of the patient's cognition and functional decline support an increase in PCW. Her condition and functional needs are at a level and unpredictable as to require the requested 84 hours/week. Based on the enclosed documents reviewed, the patient's health and safety is more appropriately provided and maintained by increasing the PCW to 84 hours/week. 

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested 7 days per week, 12 hours per day for a total of 84 hours per week of Personal Care Worker (PCW) services is medically necessary. 

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 7 days per week, 12 hours per day for a total of 84 hours per week of Personal Care Worker (PCW) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.
Treatment: Dupixent.
The insurer denied: Dupixent.
The denial is overturned.

The patient is an adult male with severe persistent asthma who has been on Dupixent for over a year. The patient has tried and failed Fasenra. The request for continuation is being reviewed.

The proposed treatment with Dupixent is medically necessary.
This patient has severe persistent asthma despite being on long acting inhaled corticosteroids as well as other asthma controller medications. The patient has tried and failed Fasenra. Since being on Dupixent, the patient's asthma is better controlled. The patient's eosinophils are not elevated in the recent labs and this is likely due to treatment with Dupixent. Not continuing Dupixent is likely to lead to destabilization of disease, worsening quality of life and more doctors visit. The current standard of clinical practice is to continue treatment with Dupixent to prevent worsening of asthma.