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

Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease

Treatment: Home Health Care/Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

The health plan denied the requested Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week as not medically necessary. 

The health plan's determination is overturned.

The patient is a female with a history of osteoarthritis (OA), Alzheimer's and diabetes mellitus (DM). They were recently hospitalized for congestive heart failure (CHF) and aspiration pneumonia. As a result, the patient has severe limitation in activities of daily living such as weight bearing support for dressing, bathing and commode use. They have stiffness, weakness, limited range of motion, incontinence and cognitive impairment. They require maximum to total assistance, as well as oxygen treatment.
At issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is medically necessary for this patient
Skilled nursing home health care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care. Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively. Care that can be given by non-professional staff is not considered skilled nursing care. The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse.
In this case, the patient has severe or extensive functional limitations which would substantiate the need for the requested health care services.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The health plan's determination is upheld. 

The patient is a female with complaints of low back pain. The pain began over 2 years ago. Prior treatment has included acupuncture, chiropractic care, massage therapy, lumbar injections, as well as medications. The Pain impacts activities of daily living. Pain ranges from 2-10 out of 10. The magnetic resonance imaging (MRI) lumbar spine reported Modic changes at disc spaces L (lumbar) 4 and L5. 

The proposed Thermal destruction of intraosseous 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. 
This procedure is not recommended at this time. Despite promising early reports, 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. 
Given the above, the Thermal destruction of intraosseous 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: Back pain. 
Treatment: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The health plan's determination is upheld. 

This is a female patient diagnosed with Vertebrogenic Low Back Pain. It was noted that the patient's primary problem is chronic low back pain due to degenerative disc disease. It was noted that the patient's low back pain began over 2 years ago. She has had multiple treatments including acupuncture, chiropractic, home exercises, injections, massage therapy, medial branch blocks, medication management, physical therapy, radiofrequency ablations, and trigger point injections. Medications have included tramadol. Pain is impacting activities of daily living, leisure activities, sleep and work and nothing has provided sustained relief. Pain is ranging from 2-10/10. The provider states the patient had an magnetic resonance imaging (MRI) performed demonstrating Modic changes at disc spaces L (lumbar)4 and L5 and therefore the provider feels that the patient's pain is coming from vertebrogenic changes at L4 and L5. 

Intraosseous Basivertebral Nerve Ablation 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 2 year history of chronic back pain and radicular symptoms. It was noted the patient's radicular symptoms have improved since undergoing a lumbar epidural injection but she continues with back pain. She has tried multiple conservative treatments including physical therapy, home exercises, trigger point injections, epidural steroid injections, Botox injections, medial branch blocks, radiofrequency ablation, and ViaDisc. The provider stated that the patient had Modic changes on MRI and feels that this is the source of the patient's pain. However, the MRI report provided does not mention any Modic changes or degenerative endplate changes and there are other findings likely responsible for the patient's pain. 
There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. 
The health plan's determination is upheld. 

This is a female who has a long history low back pain and left leg pain. Her left leg pain resolved after an epidural injection. Her back pain is associated with sitting, lifting and forward bending. Pain level ranges from 4 to 7/10. Her prior treatments include pain medications, physical therapy (PT) and spinal injections. Physical exam (PE) was unremarkable except muscle spasm bilateral paraspinal regions and tenderness over the lumbar spine. Magnetic resonance imaging (MRI) showed at L (lumbar)4/5 level: Mild spondylosis, mild bilateral facet arthrosis, and a small broad based central disc protrusion indention thecal sac, larger compared to the prior study. 

Thermal destruction of intraosseous 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 Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has persistent back pain. The MRI showed Mild spondylosis, mild bilateral facet arthrosis, and a small broad based central disc protrusion indention thecal sac, larger compared to the prior study at L4-5 level with no Modic changes documented in the MRI report. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic pain. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.
Given this patient's medical history, MRI reading, and the current clinical evidence, it is unlikely that the proposed Intracept Procedure would be beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Orthodontic Needs: Overjet, Overbite, Class 1 Malocclusion, Moderate Maxillary and Mandibular Spacing, Misaligned Midlines, History of Cerebral Palsy
Treatment: Braces ad Monthly Visit
The insurer denied braces and monthly visits.
The health plan's determination is upheld.

The patient in question is a female with a Class I occlusion with a 2 millimeter (mm) overjet and a 2 millimeter (mm) overbite. The maxillary and mandibular arches have slight spacing. She has treatment planned for orthodontics to correct her malocclusion.

At issue is the medical necessity of Braces and monthly visits.
I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of Braces, monthly visits is not medically necessary.

This patient is over the age limit for orthodontic coverage according to her insurance. That alone should result in a denial, but since there is no scientific evidence to back up that rationale we will ignore the patient's age and judge the case strictly on its orthodontic presentation.

There is no medical reason to correct her malocclusion with braces. While the patient has minor spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [1] This patient presents with none of those conditions. This patient has a Class I occlusion, and masticatory efficiency is highest in patients with a Class I occlusion. [2] If the patient's teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a past medical history (PMH) of peripheral vascular disease (PVD), diabetes mellitus type 2 (DM2), anemia, and morbid obesity status/post (s/p) gastric bypass who was admitted with complaints of (c/o) bilateral leg swelling. The patient received a course of outpatient antibiotics without improvement. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), non-ill appearing, erythema and warmth in the lower extremities with scattered ulcerations.  Imaging studies included a computed tomography (CT) scan of the lower extremities which showed extensive subcutaneous edema without abscess. The patient was diagnosed with venous insufficiency versus less likely lymphedema with superficial cellulitis and was treated with antibiotics. Vascular surgery recommended no surgical intervention. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with c/o (complaints of) bilateral leg swelling. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, did not meet systemic inflammatory response syndrome (SIRS) criteria, and there was no septicemia, life-threatening infection, necrotizing fasciitis, animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was diagnosed with likely venous insufficiency treated with antibiotics for possible superficial cellulitis, and this could have been safely provided at an observation level of care. A lower level of care is ideal for the management of mild cellulitis infections because it allows frequent reevaluation to assess response to therapy while avoiding inpatient admission. Overall, this patient could have been safely treated at a lower level of care.
The patient did not have vital sign abnormalities, hypoxemia, altered mental status (AMS), severe dehydration, necrotizing fasciitis, tissue necrosis, erythema expansion despite treatment, high temperature, metabolic acidosis, end-organ dysfunction, bacteremia, drug-resistant infection, rapidly expanding lesions, high risk location, or high-risk co-existing clinical condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cyclic vomiting syndrome
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with a history of cyclic vomiting syndrome, polycystic ovarian syndrome, dysmenorrhea, and depression/anxiety who presented to the emergency department with three days of nonbilious, non-bloody vomiting. She reported daily marijuana use, although, also said the last time she used was three days prior to admission. She said Zofran was not helping the nausea. At a prior admission, she had a normal upper endoscopy. At triage, her vital signs were normal. She was awake and ambulatory. Physical exam documented a well developed, nontoxic appearing woman in no acute distress. Mucus membranes are dry. Capillary refill is normal. The rest of the exam is normal. Electrocardiogram (ECG) was normal. Metabolic panel was normal except for a mildly low potassium at 3.2 for which she was already on home potassium supplements. She was given a normal saline bolus, Ativan and Benadryl, started on D10NS (dextrose/normal saline) at 1.5 times maintenance, and admitted to the pediatric unit.

The inpatient hospital admission was not medically necessary.
Cyclic vomiting syndrome is a difficult and frustrating clinical entity for both the patient and the treating physicians. The indication for hospitalization is significant enough vomiting that leads to dehydration and/or metabolic derangement that requires inpatient management. This patient had neither.
She said she had been vomiting for three days, but presented without apparent dehydration based on continued urination, vital signs (normal heart rate), overall appearance (non-toxic, well appearing, ambulatory), normal perfusion, and lack of acidosis or elevated blood urea nitrogen (BUN) on the metabolic panel. Although the ED (emergency department) admit note states her mucus membranes were dry, the pediatric admit note says they were not dry. Further, to whatever extent she was mildly "dry" but short of clinical dehydration, she was completely fluid repleted after the normal saline bolus.
She had a mildly low potassium at 3.2 (lower limit normal is usually 3.5), but she had no apparent clinical problems tolerating this and had potassium supplements at home.
So, while she might have been in the vomiting phase of her cyclic vomiting syndrome, she was maintaining hydration and electrolyte status at home and did not require hospitalization for that reason. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD), anxiety and depression

Treatment: Personal care aide (PCA) services, consumer direct, 1 client, 25 hours per week

The insurer denied coverage for personal care aide (PCA) services, consumer direct, 1 client, 25 hours per week

The denial is upheld 


This is an adult male with chronic medical problems including chronic obstructive pulmonary disease (COPD), anxiety and depression.  He lives alone in a 1-bedroom apartment.   In his Appeal Application, the patient writes "12.25 hours a week just isn't enough time for my attendant to help me keep my apartment clean, cook for me or run errands that I may need done, which is why I am requesting 25 hours a week."  The patient requested personal care aide (PCA) services consumer direct, 1 client, 25 hours per week.  The insurer approved personal care aide (PCA) 12.25 hours per week, leading to an external review.   

The Uniform Assessment System (UAS) report from August 2022 was reviewed.  The patient's cognitive skills are described as independent.  He is reportedly totally dependent to maximal assistance for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  However, only limited assistance or supervision is needed for lower body dressing and bathing.  The patient is otherwise independent for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation.  The patient is continent of bladder and bowel.  

The patient's self-sufficiency and ability to perform Activities of Daily Living (ADL) have not changed, and there have been no reported falls over the prior 90 days.  The patient's clinical condition and functional ability are not at a level or unpredictable as to require the requested personal care aide (PCA) services consumer direct, 1 client, 25 hours per week.  He has independent mobility and can care for himself.   Based on the enclosed documents reviewed, attention to the patient's physical needs can be appropriately provided and maintained by the approved personal care aide (PCA) services previously approved at 12.25 hours per week,

From a physical medicine and rehabilitation perspective, personal care aide (PCA) services consumer direct, 1 client, 25 hours per week are not medically necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) services, consumer direct, 1 client, 25 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a man, chronically on aspirin and Xarelto secondary to atrial fibrillation and pulmonary embolism, with prothrombin gene mutation, who was admitted to the hospital with complaints of left upper quadrant abdominal pain and an abdominal lump with ecchymosis. The patient denied trauma or injury. He reported compliance with all of his medical therapy. Vital signs showed a normal temperature, heart rate of 78, and blood pressure of 122/86. The examination was significant for a normal cardiopulmonary exam. The abdomen was soft with mild tenderness to palpation in the left upper quadrant, faint ecchymosis around the left upper quadrant, with otherwise unremarkable rest of the exam. 

Based on the provided documentation, inpatient admission was not medically necessary. Per the Milliman criteria for abdominal pain, the patient does not satisfy clinical indications for admission to inpatient care. The patient had a spontaneous rectus sheath hematoma in the setting of chronic anticoagulation and antiplatelet therapy. There was no active bleeding on the computed tomography angiography (CTA) of the abdomen; therefore, it did not require an embolization procedure. Indications for continued anticoagulation were reviewed by hematology, cardiology, and the medical team, and they felt it safe to withhold chronic anticoagulants temporarily. An inferior vena cava (IVC) filter placement, which can be completed in an ambulatory setting, was successfully established. The patient remained hemodynamically stable throughout the hospital stay, without evidence of tachycardia or hypotension to indicate ongoing bleeding. The decrease in the hemoglobin is consistent with the acute bleed and the size of the hematoma. Treatment of rectus sheath hematomas is usually supportive. Therefore, given the patient's stability, it was reasonable to complete an overnight observation with serial monitoring of labs, clinical status, and subsequent discharge home. This did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg swelling. 
Treatment: Inpatient admission. 
The health plan denied: Inpatient admission. 
The determination is upheld. 

The patient is a female with a past medical history of cirrhosis secondary to alcohol use, diabetes mellitus type 2 (DM2), gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD) and obesity status/post gastric bypass. She presented to the emergency room (ER) with worsening lower extremity edema and dyspnea on exertion. She was hemodynamically stable on admission and was afebrile. She had 4 plus (+) pitting edema, but the rest of her physical examination was normal. She had anemia, mild leukocytosis, hypoalbuminemia, an elevated bilirubin, and abnormal liver tests consistent with cirrhosis. A lower extremity doppler exam was negative for a deep vein thrombosis. She was admitted as an inpatient and started on diuretics and was sodium and fluid restricted. Gastroenterology was consulted and recommended supportive care and a diagnostic paracentesis. Her edema gradually improved. She was discharged home with instructions to follow up outpatient. 
At issue is the medical necessity of the inpatient hospital stay. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of the inpatient hospital stay was not medically necessary for this patient. 
She did not have evidence of systemic inflammatory response syndrome (SIRS) or sepsis. She was hemodynamically stable, and did not have peritoneal signs or acute on chronic liver failure. She did not have evidence of overt hepatic encephalopathy, massive ascites, hepatic hydrothorax, spontaneous bacterial peritonitis, or variceal bleeding to warrant inpatient level of care. Therefore, she could have been managed at an alternative level of care. 
Patients with advanced cirrhosis show an abnormal regulation of extracellular fluid volume, resulting in the accumulation of fluid as ascites or edema. As portal hypertension develops, splanchnic arterial vasodilation also does, due mainly to the production of nitric oxide (NO). Splanchnic arterial vasodilation decreases effective arterial blood volume, leading to fluid accumulation and renal function abnormalities, which are a consequence of the homeostatic activation of vasoconstrictor and antinatriuretic factors. The net effect is retention of sodium and water as well as renal vasoconstriction. The portal hypertension and splanchnic hyperdynamic circulation elevate the pressure of the splanchnic capillary circulation, leading to the accumulation of retained fluid as ascites. Diuretics are the treatment of choice for congestive heart failure (CHF), liver, and renal disease. Loop diuretics are usually the most effective, but several doses are required daily because of their short half-life. Patients with cirrhosis often have secondary hyperaldosteronism; therefore, spironolactone is the first choice of diuretic therapy along with furosemide.