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

Diagnosis: Varicose Veins
Treatment: Endovenous ablation therapy
The insurer denied Endovenous ablation therapy.
The determination is overturned.


The patient has left lower extremity varicose veins and was evaluated via telehealth and then in clinic.

The patient described a two year history of left lower extremity varicose veins that began during pregnancy. They did not resolve after delivery. The patient reported heaviness and discomfort in the leg. She has worn compression stockings for 3 years.

The patient was noted to have varicose veins present in the left greater saphenous vein distribution of the left leg.

The patient was offered radiofrequency ablation of the left greater saphenous vein and stab ligations of branch varicosities, 10-20 incisions.

The patient underwent radiofrequency ablation of the left greater saphenous vein and stab phlebectomy of varicosities, 10 incisions total. She was seen in follow up, and was noted to be doing well. At issue is the medical necessity of the endovenous ablation therapy.

The procedure is medically necessary. It is the standard of care for the treatment of symptomatic varicose veins and venous insufficiency. The patient has benefited from the treatment. The patient has symptomatic left lower extremity varicose veins and venous insufficiency of the left greater saphenous vein. A venous duplex exam performed revealed reflux in the proximal and midthigh portions of the left greater saphenous vein. The vein was dilated from 4 to 7 millimeters (mm). There was no reflux at the knee. There was no evidence of deep vein reflux and no thrombosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, alcohol intoxication
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female with a history of alcohol abuse, alcohol induced gastritis, anemia, seizure disorder, and polysubstance abuse who had presented to the Emergency Department (ED) for chest pain,  epigastric  pain, nausea, emesis, anxiety, myalgias, and also alcohol intoxication. 

On presentation, the patient was afebrile, pulse of 104, blood pressure of 116/87 and oxygen saturation of 97%. On examination, the patient is described as in acute alcohol withdrawal and was noted to have a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 14-15. Laboratory studies were remarkable for positive alcohol and cannabinoid. The patient received a normal saline (NS) bolus, Pepcid intravenously (IV), Zofran intravenously (IV) as an antiemetic, Tylenol, intravenous (IV) magnesium sulfate, thiamine intramuscularly (IM), Folic acid, multivitamins, Ativan intramuscular (IM), and intravenous (IV) Potassium. Upon serial monitoring, the patient had symptoms and signs consistent with failure to achieve symptom improvement further supporting the necessity of acute inpatient care.

No, the proposed inpatient admission was not medically necessary.
The treatment and care as rendered were medically appropriate but not medically necessary at the level at which it was provided.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient presented for detoxification; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  The patient improved with emergency department management and did not evidence tremulousness or sweating that worsened at all during observation level care. As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the ED (emergency department) of the facility filing the appeal with gastrointestinal bleeding. The patient reported rectal bleeding, rectal pain, chills, nausea, and emesis for two days. The patient noted decreased oral intake and decreased urination. The patient also reported a dry cough and a headache.

The patient evidenced tachycardia on presentation and a temperature of 99.3. The patient had left lower quadrant pain on physical examination. A CT (computed tomography) scan showed thickening of the entire colon consistent with colitis. A GI
(gastroenterology) consultant recommended no antibiotics.  However, as time passed and the situation changed, antibiotics were started and the patient was admitted for supportive care. Studies returned with Shigella noted. The patient signed out AMA (against medical advice).

No, the Inpatient admission was not medically necessary.
The care as provided was appropriate, but not medically necessary at the level at which it was provided.

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension,
signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, need for blood products or a blood transfusion, severe
electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Gynecologic Issues
Inpatient Hospital

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

The patient underwent a laparoscopic hysterectomy, bilateral salpingectomy secondary to menorrhagia and pelvic pain. There were no complications during or after the planned, elective surgery. She was admitted as an inpatient and was discharged the following day.
At issue is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.
The patient had no acute findings or conditions that would support the need for inpatient admission. She had no hemodynamic instability and vital signs were normal. She had no hemorrhage nor need for blood transfusion. She had no renal, cardiac, nor hepatic morbidities. She was also discharged less than 24 hours later which supports the need for a lower level of care only. Her hysterectomy was without complication and bleeding was minimal. She had no complications of infection nor poor wound management. She had no anesthesia complications. She could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain. 
Treatment: Nerve Treatment in the Spine. 

The insurer denied Nerve Treatment in the Spine. 
The determination is overturned. 

The patient has a one-year history of back pain. The patient had failed physical therapy (PT), nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid medications. The physical exam (PE) of lumbar spine was unremarkable with no tenderness to palpation, negative facet loading, negative Patrick's test, negative Gaenslen's test and negative straight leg raising test. Magnetic resonance imaging (MRI) is remarkable for anterior endplate marrow edema lumbar (L) 4-5 and fatty endplate degenerative changes at L5-sacral (S) 1. 

At issue is the medical necessity of the Intracept procedure. 

The requested procedure is medically necessary. 
This patient has persistent back pain consistent with vertebrogenic pain from her L4-5 and L5-S1 degenerative endplate changes (Modic changes). She had failed extensive treatments including physical therapy (PT) and pain medications. An MRI revealed a finding of Modic changes at L4-5 and L5-S1 levels. Further interventions are medically necessary for pain relief. The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrated the efficacy of this intervention in the treatment of vertebrogenic pain. Given this clinical scenario, it is medically necessary to consider intracept procedure as the next step treatment.
Appeal type: Medical necessity
Decision: Upheld


diagnosis: bilateral lower extremity swelling 
Treatment: inpatient hospital
The insurer denied an inpatient stay. The health plan's determination is upheld.

The patient is a male with a past medical history remarkable for polysubstance abuse, bipolar disorder, hepatitis C, and chronic venous insufficiency, who was admitted for lower extremity swelling. Review of system was positive for blood-streaked vomitus, diarrhea, and occasional melena. The patient was admitted for bilateral lower extremity swelling due to chronic venous insufficiency. Dopplers were negative for thrombosis. Chest x-ray revealed mild linear atelectasis or scarring of the right lung. The patient was subsequently discharged.

The inpatient hospital admission was not medically necessary.
The patient was admitted for lower extremity swelling due to chronic venous insufficiency. The documentation does not support an acute inpatient admission based on the lack of systemic symptoms such as fever (> [greater than] 100.4) or leukocytosis, evidence of deeply seated infection such as osteomyelitis, septic arthritis, or presence of significant comorbid conditions that increases the risk of complications (e.g., immunocompromised state).
Chronic Venous Stasis (CVD) can be treated at a lower level of care. The goal of CVD treatment is to decompress sources of increased venous pressure. Initial therapy with graduated compression stockings is recommended for most patients. More aggressive initial treatment may be considered in patients who present with complications such as recurrent superficial vein thrombosis, bleeding varicose veins, or ulceration. Patients do not typically require hospitalization unless there are associated complications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Inflammatory Bowel Disease
Treatment: Stelara
The insurer denied Stelara.
The determination is overturned.

The patient has a history of very early onset inflammatory bowel disease, likely ulcerative colitis (UC). She has tried and failed infliximab and conventional therapy. The requested service is Stelara, which is under review for medical necessity.

Yes, Stelara is medically necessary in this case.
Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer-reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease.
A report by Dayan JR et al, showed that ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease.
Per Dhaliwal, Jasbir, et al: " Ustekinumab demonstrated efficacy in this paediatric cohort with otherwise treatment-refractory UC".
This patient has a history of refractory inflammatory bowel disease, which failed anti- tumor necrosis factor alpha (infliximab) and conventional therapy. Humira is unlikely to be effective as it has a similar mechanism of action to infliximab. There are no other suitable treatment alternatives beside Stelara. Therefore, Stelara is medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 minutes 24 hours per day (live in). 
The insurer denied Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 minutes 24 hours per day (live in). 
The health plan's determination is overturned. 

The is a female with past medical history of dementia, macular degeneration with blindness, atrial fibrillation, hallucinations, anxiety, insomnia, and urinary incontinence who had been assigned PCS (personal care services) following an assessment that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication and transportation. With tasks of phone use, stairs, bathing, dressing lower body, and toilet use, the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene and dressing upper body. The patient was assessed at supervision with tasks of walking, locomotion, transfer toilet, and eating and was assessed as independent with task of bed mobility. 

Home Care / Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 minutes 24 hours per day (live in) is medically necessary for this patient.
There is documentation of functional and cognitive decline over a period of several months with recurrent falls also documented. The patient has a diagnosis of dementia which is a progressive medical condition where functional and cognitive decline can occur. The patient's recent assessment underestimated some of the patient's care needs as there was a reported improvement in some of the patient's assistance needs compared to the previous assessment which would be unlikely given her fall, head injury, and hospitalization. The patient requires at least extensive assistance with transfer toilet and toilet use and supervision with walking and locomotion. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCS is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The plan also assumed the patient's family would be able to provide informal support outside of the hours of current PCS, but they are not able to provide this amount of support. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested PCS hours are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; headaches/trigeminal neuralgia
Treatment: Electrical Stimulator for the Nerves Near the Base of Head 
The insurer denied an Electrical Stimulator for the Nerves Near the Base of Head. The health plan's determination is upheld. 

This is a male with a 20-year history of occipital and trigeminal neuralgia. He has had injections and medications without relief. The neurologic exam shows no abnormalities. The brain magnetic resonance imaging (MRI) shows vascular contact of the SCA (superior cerebellar artery) with the trigeminal nerve. The provider has recommended an occipital nerve stimulator trial. 

The Electrical Stimulator for the Nerves Near the Base of Head is not medically necessary for this patient.
Based on the current medical literature, occipital nerve stimulation for occipital neuralgia or headaches would be considered not medically necessary. While this is a promising technology, the current literature relates that further studies are needed to show the efficacy of the procedure. This process may require additional studies, at least for approval from the US (United States) Food and Drug Administration. There are still concerns over the risk to benefit ratio and effectiveness of ONS (occipital nerve stimulation)  despite positive open-label data and a well-designed double-blind controlled trial with long-term follow-up is needed to clarify the position of neuromodulation in chronic migraine.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hemiparesis, hemiplegia

Treatment  long term custodial care continued stay

The insurer denied coverage for long term custodial care continued stay 

The denial is overturned 

The patient is a man with left hemiparesis, hemiplegia, hypertension, dysarthria, COVID-19 (2019 Novel Coronavirus), osteoarthritis, angina pectoris, and muscle weakness. The patient was wheelchair bound. The patient is in a skilled nursing facility. The patient was walking 200 feet with a wide based cane and a rollator with supervision. He required supervision for transfers. He was considered contact guard for upper body dressing, toileting, moderate assist for lower extremity (LE) dressing.  He did not increase his flexion goals. The patient has finger contractures for which he received Botox. He has had hand pain as well and was on Tramadol and duloxetine. The patient was discharged from physical therapy (PT) and occupational (OT). The patient has been a long-term resident in the nursing home. 

In review of the records the patient does not appear to be at supervision level for all activities of daily living. He is dependent on assistance for most activities of daily living (ADLs) per the note.   Long term custodial care continued stay is considered medically necessary for this patient.
   
The notes are quite difficult to follow, as the PT/OT notes do not actually identify all ADLs that were attempted. While he is ambulating, he is not able to use his left-hand function at all for anything and therefore, cannot dress fully, requires assistance with transfers, likely with bowel movements. Based on the provided documentation the patient continues to require 24 hour care. There is chronic depression and one note mentioned dementia as well.

"When considering the outcome state of nursing home (NH) placement, it is important to recognize that, for some vulnerable, dependent persons, moving to a NH may result in greater safety and better quality of life." (Mor et al., 2018).

" Long term care (LTC) refers to a broad range of services designed to provide assistance over prolonged periods to compensate for loss of function due to chronic illness or physical or mental disability.1 LTC includes hands-on, direct care as well as general supervisory assistance. The type, frequency, and intensity of services vary; some people need assistance for a few hours each week, whereas others need full-time support. LTC differs from acute or episodic medical interventions because it is integrated into an individual's daily life over an extended time.2" (Wysocki et al., 2013).

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

The insurer's denial of coverage for long term custodial care continued stay is   overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart disease, chronic kidney disease (CKD), hypertension, gastroesophageal reflux disease (GERD). 

Treatment: Personal care services 12 hours per day, 7 days per week, totaling 84 hours per week. 

The insurer denied coverage for personal care services 12 hours per day, 7 days per week, totaling 84 hours per week. 

The denial is modified. 

This is a patient with chronic medical problems including heart disease, chronic kidney disease (CKD), migraines, obstructive sleep apnea (OSA), ulcerative colitis (UC), atrial fibrillation and osteoarthritis.  She lives in a 4-bedroom apartment on the 3rd floor of a building with an elevator.  The plan approved personal care services (PCS) 6 hours a day (4 days a week), 7 hours a day (2 days a week) and 2 hours a day (1 day a week), totaling 40 hours/week.  Under review is the medical necessity for personal care services 12 hours per day, 7 days per week, totaling 84 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognitive ability is described as "minimally impaired."  She requires extensive to maximal assistance for dressing, personal hygiene and toilet transfer/use.  She is incontinent of bladder (uses straight catheter every 2 hours) and has an ostomy for bowel management.  Her cognitive and functional impairments do not support the medical necessity of the requested 12 hours per day, 7 days per week, totaling 84 hours per week.  However, increasing PCS to a more consistent 7 days x 7 hours (49 hours/week) is clinically appropriate and medically necessary in order to allow her to continue living safely at home. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, personal care services 12 hours per day, 7 days per week, totaling 84 hours per week is not medically necessary.  However, increasing PCS to a more consistent 7 days x 7 hours (49 hours/week) is clinically appropriate and medically necessary. 

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

The insurer's denial of coverage for personal care services 12 hours per day, 7 days per week, totaling 84 hours per week is modified. Medical Necessity is substantiated for 7 days x 7 hours (49 hours/week).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Benign neoplasm of connective and other soft tissue-vascular malformation
Treatment: sirolimus compound
The insurer denied sirolimus compound
The determination is overturned.

The patient has a benign neoplasm of connective and other soft tissue-vascular malformation. His vascular malformation is associated with painful blebs, frequent bleeding, and the leakage of lymphatic fluid. The blebs are not only painful but they limit his regular daily activities. The treatment under review is compounded sirolimus.

Given the patient's diagnosis and current health status, the proposed treatment, sirolimus powder, is medically necessary. The patient has a lymphatic malformation with associated pain. The safest treatment that has shown efficacy is topical sirolimus. Per the most recent literature, almost all references to any current literature about lymphatic malformations reference topical sirolimus as effective. Cai et al writes "Moreover, in this cohort study, 54 although two cases were reticulate in appearances and three had combined vascular 55 anomalies, the patients responded well to topical rapamycin" (1). Similar reports detailing the efficacy of topical tacrolimus for microcystic lymphatic malformations are echoed throughout the 2019 dermatology literature (2,3). The other, more conventional treatments- such as sclerotherapy, excision, laser treatments- mentioned in the textbooks (which are not as up to date as the current literature) carry greater risk as in that age group general anesthesia for those treatments would be required, and likely repeat treatments. A sirolimus tablet/solution would not be appropriate for this patient.  Oral sirolimus has a significantly higher side effect profile, including symptoms such as fever and rash, and would not be appropriate in this patient.   
Therefore, the proposed treatment, topical sirolimus (compounded), is medically necessary.