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

Diagnosis: Hypertension, diabetes and peripheral edema

Treatment: Personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week

The insurer denied coverage for personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week

The denial is modified.

 
This is an elderly female with chronic medical problems including hypertension, diabetes and peripheral edema.  She lives alone in a private residence.  The plan approved personal care aide (PCA) 28 hours/week.  The patient requested level 2: 8 hours per day, 7 days a week totaling 56 hours/week, denied by the insurer; leading to an external review.   

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent.  She is reportedly totally dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient also reportedly requires maximal assistance for bathing.  Limited assistance is reportedly needed for dressing, locomotion, toilet transfer/use and ambulation. The patient is independent with personal hygiene, bed mobility and eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.   Her activities of daily living (ADL) status has declined and there have been no reported falls over the prior 90 days. 

The patient's cognitive and functional ability have declined when compared to the prior UAS report. The Emergency Department note does not specifically address the patient's functional ability.  This physician would agree that the patient may benefit from monitoring for safety; particularly due to her reported cognitive deficits, weakness and falls risk.  PCA services for companion care or safety supervision (e.g., dementia, wandering, falls risk) without the direct provision of ADL task assistance is not a covered service.  However, given her modest cognitive and functional decline and based on the enclosed documents reviewed, this patient's health and safety are more appropriately provided and maintained by increasing PCA 6 hours/day, 7 days/week, totaling 42 hours/week.  

Based on the above, the insurer's denial must be modified. 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) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week services is not substantiated. However, PCA level 2: 6 hours/day, 7 days/week, totaling 42 hours is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: epigastric pain, nausea and vomiting

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult female who presented to the emergency department (ED) complaining of abdominal pain with a 1 day history of epigastric pain, nausea and vomiting. The pain was constant in her abdomen. She had similar pain in 2022 when she was diagnosed with symptomatic cholelithiasis and declined elective surgery.  On exam she had tenderness in the right upper quadrant (RUQ) without rebound or guarding. Murphy's sign was negative. She was afebrile. The assessment was suspect cholecystitis versus symptomatic cholelithiasis. The plans were right upper quadrant (RUQ) ultrasound and surgical consult. White blood cells (WBC) were 8.02 and liver function test's (LFT's) were normal. Ultrasound of the abdomen revealed cholelithiasis without evidence of acute cholecystitis. There was no biliary duct dilation. 

The patient underwent an uneventful laparoscopic cholecystectomy and pathology revealed chronic cholecystitis and cholelithiasis. Post operative pain was well controlled. The patient denied nausea or vomiting, and the patient was discharged home the day after surgery.

The acute inpatient admission was not necessary as this patient should have been managed in an ambulatory/observation setting per Milliman Care Guidelines (MCG).

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hand pain and swelling
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who was hospitalized secondary to left hand pain and swelling. He previously, he "scratched" the palm of his left hand at work. Approximately 2 days prior to presenting to the emergency department, he was evaluated in the ambulatory setting and prescribed oral cephalexin without significant clinical benefit. An x-ray of the hand did not reveal the presence of a foreign body. Initial laboratory data demonstrated mild leukocytosis (11,600) and elevated inflammatory markers (erythrocyte sedimentation rate (ESR) 35, C-reactive protein (CRP) 50.7). An incision and drainage procedure was performed in the emergency department. Wound culture ultimately grew methicillin-resistant staphylococcus aureus (MRSA). Initial treatment included the provision of intravenous antibiotic therapy and wound care. Clinical improvement was noted, and he was discharged home with prescribed oral antibiotics. At issue is the medical necessity of an inpatient stay.

Based on the information provided, the requested service of inpatient admission was not medically necessary for the patient. This patient was afebrile, hemodynamically stable, and tolerating oral intake. While this patient required medical treatment (e.g. incision and drainage, provision of intravenous antibiotic therapy), it was not medically necessary for this treatment to be provided in the acute inpatient care setting. The medical care provided to this patient could have safely and effectively been delivered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sinus perforation on the upper left
Treatment: Primary Closure of a Sinus Perforation for the Upper Left Area
The insurer denied Primary Closure of a Sinus Perforation for the Upper Left Area
The health plan's determination is upheld. 

The patient is a female who was denied closure of a sinus perforation on the upper left. The documentation consists of an undated panoramic radiograph which shows tooth #14 is missing the crown and the tooth has had a root canal procedure. The roots appear to extend to the floor of the sinus. There is no sinus pathology noted.

The Primary Closure of a Sinus Perforation for the Upper Left Area is not medically necessary for this patient.
Based on the limited information provided, it is unclear if this is a pre-authorization or if treatment has been completed. It appears that the treatment has not yet been completed. Therefore, there can be no sinus exposure until the tooth is removed. In addition, removal of the tooth may not result in a sinus exposure. In order to determine the medical necessity of sinus closure, it would require at a minimum an operative report to be provided which documents this and preferably a photograph showing the sinus exposure.
Oral antral communications (OACs) may close spontaneously especially when the defect has a size smaller than 5 mm. Nevertheless, it has never been actually proven that small OACs (< 5 millimeter (mm)) will heal by themselves. Currently, closure of OACs is usually performed by a surgical procedure. In case of a small OAC, suturing the gingiva might be sufficient to close the perforation. When this does not provide adequate closure, a flap procedure is the treatment of choice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied braces and monthly visits.
The determination is upheld.

The patient is a female with a Class II right malocclusion, moderate maxillary crowding and moderate mandibular crowding, mild overjet and mild overbite. The issue is whether the service/treatment of braces and monthly visits is medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include cleft palate deformity or craniofacial anomaly, deeping impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment of braces and monthly visits are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain

Treatment: Low back pain (procedure codes 64628 & 64629), DOS (date of service) TBD (to be determined)

The insurer denied coverage for low back pain (procedure codes 64628 & 64629), DOS (date of service) TBD (to be determined).

The denial is upheld.

The patient is seeking authorization for Intracept interosseous basivertebral nerve (BVN) ablation at L (lumbar) 3-S (sacral) 1 (64628, 64629).

Magnetic resonance imaging (MRI) of the patient's lumbar spine noted slight L3 retrolisthesis and a shallow lordosis.  There was left convex scoliosis centered at L3-4.  There were fatty marrow endplate changes at L3-4 secondary to chronic disc degeneration.  There was mild narrowing of the right neural foramen at L4-5 due to protruding disc margin.  There was loss of disc height at L5-S1 without compromise of the spinal canal or neural foramina.  

The patient presented for an evaluation related to low back pain and left hip pain.  The patient reported low back pain with radiating symptoms into the left hip and groin and lateral aspect of the left hip into the knee.  The patient reported that the axial back pain was significantly more bothersome than the leg and hip pain.  Prior treatments included gabapentin, lidocaine patches, Tylenol, nonsteroidal anti-inflammatory medications, greater trochanteric bursa injection, physical therapy, and epidural steroid injections.  The patient continued to have significant pain which impinged on activity and quality of life.  The physical exam findings of the patient noted limited range of motion of the lumbar spine.  There was 4 out of 5 strength with bilateral hip extension.  The patient's sensation was intact in the bilateral lower extremities.  There is diffuse tenderness over the lumbar paraspinals.  There was tenderness to palpation over the left greater trochanter.  There is tenderness to palpation over the bilateral sacroiliac joints.  Radiographs of the lumbar spine noted marked disc space narrowing at L5-S1, moderate to space narrowing at L3-4, and mild to space narrowing at L2-3.  There was mild facet arthrosis in the lower lumbar spine.  The patient was assessed with lumbar spondylosis, vertebrogenic low back pain, lumbar degenerative disc disease, and lumbar facet arthropathy.  There is a plan for bilateral medial branch block at L4-5 and L5-S1 and Intracept intraosseous nerve ablation at L3-S1.

In summary, the denial of low back pain (procedure codes 64628 & 64629) DOS (date of service) TBD (to be determined) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tracheomalacia with prolapsing epiglottis. 
Treatment: Durable Medical Equipment (DME): High Flow Humidifier (E1399RR x6).
The insurer denied Durable Medical Equipment (DME): High Flow Humidifier  (E1399RR x6). 
The health plan's determination is overturned. 

The patient is a male child born prematurely at 35 weeks' gestation with complex genetic disorder, unbalanced translocation 4:15, increasing his risk of global developmental delay. After delivery, he was diagnosed with jejunal atresia with re-anastomosis at 62 days of life, and later was diagnosed with tracheomalacia with prolapsing epiglottis requiring supraglottoplasty and tracheostomy tube placement. Additional diagnoses included fibrolipoma of the filum terminale so far with normal lower extremity motor function (concerned for tethered cord), possible congenital Horner's syndrome, bicuspid aortic valve, radial ray anomalies, hypospadias with penile chordee, failed hearing screen, history of hydronephrosis that has resolved. A gastrostomy tube was placed for fluids and nutrition. 

The requested durable medical equipment (DME) is medically necessary for this patient.
Tracheal plugging is a preventable life-threatening complication of tracheostomy tube placement. Adherence to airway clearance with saline and suctioning is crucial and sufficient to reduce occurrence of mucus obstruction for most patients. For this young patient, routine airway clearance with saline lavage and suctioning is not sufficient to prevent mucus plugging. He has demonstrated need for higher level of care to prevent this source of morbidity and even mortality. While hospitalized, he exhibited improvement in secretion production, secretion thickness, coughing with the use of the Airvo high flow system. This device is medically necessary for this child to provide essential humidification and airflow to prevent unnecessary and potentially catastrophic complications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness 
Treatment: Brain CT (computed tomography)

The insurer denied Brain CT (computed tomography).  The determination is upheld.

This is a female patient who has a listed diagnosis of "dizziness and ringing in ears." It is unclear how such a diagnosis was established. A very limited history is handwritten and not entirely intelligible. There is no detailed examination documented. An electroencephalogram (EEG) reports a diffusely slow background. A brain computed tomography (CT) scan is requested and is under review for medical necessity.
The computed tomography scan is not medically necessary. Given a lack of standard medical documentation, medical necessity is not established. A minimum of a legible detailed history, with a detailed medical and neurological examination are considered standard of care and required for establishing medical necessity; this was requested but not received. The submitted medical records do not establish medical necessity, lacking a detailed, intelligible history, and a detailed examination. In the absence of such minimum standards of medical care, detailed and intelligible history and medical examination, medical necessity cannot be established. As early as 2002, the importance of intelligible medical records was promoted by Rodriguez-Vera and multiple other authors. Tribble, as recently as 2019, has also advocated for proper documentation. In addition, given its limited ability to visualize the posterior fossa, a computed tomography (CT) scan is not generally considered appropriate imaging for evaluation of dizziness.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented with abdominal pain, nausea, and vomiting. The patient had a history of liver cancer and severe hepatic steatosis. The patient has continued to drink alcohol heavily. The patient was afebrile and vital signs were stable. There was no abdominal rebound or guarding. An abdominal computed tomography (CT) scan showed a stable liver mass. The patient was diagnosed with acute gastroenteritis. The glucose was 245 with a carbon dioxide (CO2) of 10.6. However, several hours later the glucose was 92 with the CO2 up to 16. IV fluids and Zofran were given in the emergency room (ER). Afterwards, the patient wanted to eat and was tolerating a diet by the time of admission. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-170 for Gastroenteritis. Clinical indications for admission include having a severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetics, and severe electrolyte abnormalities that do not correct despite observation treatment. The patient did not have these conditions. 

This patient had hepatocellular carcinoma but was not in acute liver failure. The patient was diagnosed with gastroenteritis. The acidosis rapidly improved. There were elevated troponins but the patient was not diagnosed with any acute cardiac condition. Intravenous (IV) hydration and antiemetics could have been given in the ER with observation care. The patient had already improved by the time of admission. The patient did not meet MCG criteria for admission for Gastroenteritis. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult male with a history of clinically localized prostate cancer who underwent robotic assisted radical prostatectomy, lymph node dissection 7 months ago. The procedure was uncomplicated. The post-operative note indicated the patient was doing well after surgery. The patient denied fever, chest pain, shortness of breath, nausea, or vomiting. 
Postoperative pain was well managed. The patient's intravenous access was discontinued, and the patient was started on clear liquids. He was ambulating postoperatively. Overnight, the patient's urine output decreased, and he was given a fluid bolus. On postoperative day 1, the patient's urine was clear, he was pain free, clinically stable, and discharged to home. Inpatient stay was denied as not medically necessary as it does not meet InterQual 2022 acute general surgery post-operative day 1 (POD:1) criteria.

The requested health service was not medically necessary.

This is an otherwise healthy male who underwent an uncomplicated robotic radical prostatectomy who was noted to be doing well on his postoperative check. He was ambulating and tolerating liquids. His pain was controlled. Outside of a decrease in urine output responsive to intravenous fluids, the patient had no other medical issues, and nothing reported requiring the acuity of care requested. His postoperative care could have been managed at a lower level of care. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: ulcerative colitis
Treatment: Stelara (ustekinumab) Intravenous (IV)
The insurer denied Stelara (ustekinumab) Intravenous (IV)
The health plan's determination is upheld.

This is a female patient with a history of ulcerative colitis. She has tried and failed mesalamine and corticosteroids. The requested service is Stelara.
Stelara is not medically necessary. 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 refractory inflammatory bowel disease.
According to Koudsi, Mounzer, et al., "In this retrospective, multicentral study, ustekinumab proved to be efficient in pediatric patients resistant to anti-TNF (tumor necrosis factor). The Pediatric Crohn's Disease Activity Index (PCDAI) has been significantly improved in patients with severe disease treated with Ustekinumab."
Therefore, the off-label use of Stelara in refractory cases of pediatric ulcerative colitis is appropriate. However, the records do not show that the patient has tried and failed the FDA-approved alternatives, such as infliximab or adalimumab. There is no evidence that Stelara is superior to the FDA-approved alternatives in terms of safety or efficacy in children with ulcerative colitis. The patient has no documented contraindications to infliximab or adalimumab.
Therefore, this patient does not have refractory disease, and the off-label use of Stelara is not necessary before failing the available and FDA-approved therapies.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: moderate maxillary and mandibular crowding.
Treatment: braces.
The insurer denied braces. 
The health plan's determination is upheld. 

The patient is a female with moderate maxillary and mandibular crowding. The patient has a class II occlusion with a 4-millimeter (mm) overjet and 5mm overbite. The orthodontic problem list includes a buccal crossbite on tooth #13. The patient's is treatment planned for 24-30 months of braces to align the teeth and correct the bite. 

Braces are not medically necessary for this patient.
She has crowding but no teeth are impacted. Her overbite is deep but there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows the lower incisors are contacting the cingulum of the upper incisors in occlusion. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. The records provided do not support the diagnosis of a complete buccal crossbite on tooth 13 but a crossbite is not detectible on the records provided. Additionally, if tooth 13 was in buccal crossbite one would expect tooth 20 to be displaced to the lingual due to the abnormal occlusal forces from tooth 13. Tooth 20 is not displaced to the lingual.
While the patient has crowded teeth, there is no evidence of wear or periodontal recession. There are functional problems that may occur in dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. The patient has a 4mm overjet, but research shows overjet would not affect oral health-related quality of life unless it was greater than 6mm. If her 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, braces are not medically necessary.