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

Diagnosis: Hypertension, osteoarthritis, and Alzheimer's disease
Treatment: Personal care worker (PCW) two 12-hour split shifts per day, 7 days per week
The insurer denied coverage for personal care worker (PCW) two 12-hour split shifts per day, 7 days per week.
The denial is upheld.

The patient is an elderly female with chronic medical problems including hypertension, osteoarthritis, and Alzheimer's disease. She lives alone in a 1-bedroom apartment. She has been approved for personal care worker (PCW) services 8 hours/day, 7 days/week. The patient is requesting an increased in PCW services; two 12-hour split shifts per day, 7 days per week.

According to the Uniform Assessment System (UAS) report the patient cognitive status is described as "minimally impaired." The patient requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for upper body dressing, ambulation, and toilet transfer/use. She is frequently incontinent of bladder and infrequently incontinent of bowel. Limited assistance is needed for personal hygiene.  

A letter was submitted by her treating psychiatrist. She indicated, "[a]fter her husband passed away, she became disorganized and has frequent episodes of falling down, unable to take care of her everyday needs, has episodes of wandering the streets at nighttime when she is alone."  

The UAS specifically says no wandering. Also, no falls in the last 90 days.
She is frequently incontinent of the bladder. She is infrequently incontinent of bowel. A letter from her doctor says she has difficulty ambulating and is "prone to falls" but no specifics regarding any falls are mentioned and it concludes she needs assistance 24/7 but there is no mention of a need for split shifts but for nutrition, safety, prevention of falls and accident. The combination of the patient's cognitive status, functional impairments and recent decline support the medical necessity of increasing PCW services. This physician would agree the patient may require 24-hour monitoring. However, safety monitoring (e.g., for dementia) under PCW services does not include monitoring an individual when no other Level I or Level II personal care service task is being provided.  In addition, her condition and functional needs are not at a level or unpredictable as to require the requested personal care worker (PCW) two 12-hour split shifts per day, 7 days per week. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing PCW services to 12 hours/day, 7 days/week for a total of 84 hours.  

The healthcare plan acted reasonably with sound medical judgment and in the best interest of the patient.  

The requested personal care worker (PCW) services; two 12-hour split shifts per day, 7 days per week is not medically necessary.  

Based on the above, the insurer's denial must be upheld. The medical necessity for personal care worker (PCW) two 12-hour split shifts per day, 7 days per week services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation, anemia, high blood pressure, heart failure
Treatment: Requested increase in personal care worker (PCW) services from 7 days per week, 4.5 hours per day (31.5 hours per week) to 12 hours per day, 84 hours per week
The insurer partially denied a requested increase in personal care worker (PCW) services from 7 days per week, 4.5 hours per day (31.5 hours per week) to 12 hours per day, 84 hours per week.
The denial is overturned.

This is the case of an elderly female with a history of atrial fibrillation, anemia, high blood pressure, heart failure (on Bumex), transitional cell carcinoma of the ureter, status post stent placement (stent replacement required every 6 months), lower extremity edema, prediabetes, anxiety, and depression. Per the telehealth office visit note, the patient has generalized weakness with history of falls, shortness of breath with exertion, unsteady gait, difficulty standing/transferring and urinary and bowel incontinence. The submitted evening log notes the patient has difficulty changing her diapers and that episodes of incontinence have increased. An increase in personal care worker (PCW) hours is requested.

The documentation provided shows an elderly woman with several underlying conditions. Simply stated, she is not independent. She has problems arising, standing, and walking. She is at extreme risk for fall with resultant fracture. She is incontinent and unlikely to change or remove her own diaper. These findings have been reported daughter (in attendance and on camera). Her physician has documented her clinical status and supports the necessity of increased care. The interview experience was noted by daughter where no physical examination was performed to assess current limitations. The condition is progressed over a period of months with no likelihood of improvement. It would be extremely important to provide the requested services to avoid probable complications. 

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

The requested increase in personal care worker (PCW) services from 7 days per week, 4.5 hours per day (31.5 hours per week) to 12 hours per day, 84 hours per week is considered medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. The medical necessity for a requested increase in personal care worker (PCW) services from 7 days per week, 4.5 hours per day (31.5 hours per week) to 12 hours per day, 84 hours per week services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Pain
Treatment: Oxycontin 30mg
The insurer denied: Oxycontin 30mg
The denial is upheld

This patient is an adult female with chronic pain who has been prescribed OxyContin 30 milligrams (mg). No physical exam is attached. The requested medication was denied as formulary alternatives have not been failed.

The patient is an adult female who was prescribed OxyContin 30 milligrams (mg) for chronic pain. The requested medication was denied as formulary alternatives have not been failed. There is no extenuating circumstances that would necessitate the need of OxyContin outside of the formulary alternatives. There is no data or literature to support that OxyContin is more efficacious than the formulary alternatives. In fact, risks of diversion or abuse are lower with some of the formulary alternatives listed. These include Nucynta extended release (ER); oxycodone extended-release; Xtampza extended-release (ER); morphine extended-release; oxymorphone extended-release; hydrocodone extended-release tablet; hydromorphone extended-release; fentanyl extended-release patch; tramadol extended-release; and methadone. There is no data to suggest that the formulary alternatives would be ineffective for this patient. There is no data to suggest that the formulary alternatives would have an adverse effect on this patient. Given the above, the requested medication is not medically necessary without having first failed formulary alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic migraines.
Treatment: Pain Management; 64400 x 3 (trigeminal nerve block).
The insurer denied coverage for pain Management; 64400 x 3 (trigeminal nerve block).
The denial is upheld.

This patient has chronic migraine headache without an aura and occipital neuralgia. The HP (history and physical) refers to trigeminal neuralgia in their denial but that is NOT mentioned in the medical records.

While there is some evidence (1,2) supporting the use of occipital nerve blocks (ONB) for chronic migraine, there is no evidence based clinical practice guidelines that support the use of trigeminal nerve block for chronic migraine. Blumenfeld et al (1) "Our clinical experience supports the use of trigeminal nerve blocks in combination with ONB for some patients, especially those who do not respond well to ONB alone. Headache location and local tenderness over a trigeminal nerve branch may help in selecting the appropriate nerve(s) for blockade. Blocking multiple trigeminal nerve branches in a circumferential fashion may prove effective in refractory patients. We encourage the performance of further studies to address this question."

Similarly, a Consensus statement (2) was published, and it concluded: "It should be noted that there is a paucity of evidence from controlled studies for the use of Peripheral Nerve Blocks in the treatment of primary and secondary headache disorders, with the exception of Greater Occipital Nerve blockade for Chronic Headache. Further research on this topic is strongly encouraged, and may result in revision of the said recommendations, aiming at further improving the outcome and safety of this treatment modality for headache"

The use of Trigeminal Nerve Blocks for migraines is still considered investigational/ experimental and is NOT more likely to beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of Pain Management; 64400 x 3 (trigeminal nerve block) should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute infarct of the left cerebellum
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a male who initially presented to the emergency department with a frontal headache and intermittent dizziness of one day duration. Initial vital signs revealed a temperature of 98.3oF, heart rate (HR) 75, blood pressure (BP) 106/57, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 98% on room air. Initial examination documented the patient as alert and oriented with mild inflammation to right upper gum line. An electrocardiogram (EKG) revealed sinus bradycardia without acute ischemic changes. A computed tomography (CT) head revealed no acute intracranial hemorrhage.  A CT angiogram of the brain was performed and revealed an acute infarct involving the left cerebellum. 

The inpatient hospital admission was medically necessary.

Yew et al. note stroke can be categorized as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Awakening with or experiencing the abrupt onset of focal neurologic deficits is the hallmark of the diagnosis of ischemic stroke. The most common presenting symptoms of ischemic stroke are speech disturbance and weakness on one-half of the body. The most common conditions that can mimic a stroke are seizure, conversion disorder, migraine headache, and hypoglycemia. Taking a patient history and performing diagnostic studies will usually exclude stroke mimics. Neuroimaging is required to differentiate ischemic stroke from intracerebral hemorrhage, as well as to diagnose entities other than stroke. The choice of neuroimaging depends on availability of the method, the patient's eligibility for thrombolysis, and presence of contraindications.

In this particular situation, the patient presented with a significant new headache and dizziness of 24 hour duration. An extensive evaluation was performed including a CT angiogram of the brain which revealed an acute infarct of the left cerebellum. This was confirmed by an MRI of the brain. Neurology consultation was obtained whom had such concern regarding the etiology of the ischemic stroke that a transesophageal echocardiogram was ultimately pursued. Once the diagnostic evaluation was completed, the patient was discharged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip fracture.
Treatment: Home health care.
The insurer denied Personal Care Worker (PCW): 12 Hours per Day, 7 Days per Week . The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, hyperlipidemia, restless leg syndrome, lumbar disc disorder with radiculopathy, dementia, lymphedema, anxiety, depression, asthma, coronary artery disease, gastroesophageal reflux disease (GERD), neuropathy, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, chronic anticoagulation, and urinary and bowel incontinence who had PCW (personal care worker) services. The patient had a fall with resultant hospitalization for operative management of left hip fracture and was subsequently discharged to Skilled Nursing Facility (SNF) with discharge to home with visiting nurse services. There was a request to increase PCW services.

Personal Care Worker (PCW): 12 Hours per Day, 7 Days per Week are medically necessary for this patient. 
There is documentation from the patient's primary care physician of medical necessity of increased PCW services. There is documentation from the patient's PCP (primary care provider) and hospital records of worsening physical functioning following hip fracture. There is documentation from the universal assessments of an increased need of assistance with multiple Instrumental activities of daily living (IADL) and activities of daily living (ADL) when comparing the assessments, specifically, tasks of meal preparation, phone use, stairs, shopping, transportation, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. 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 patient does not have informal help outside of the currently assigned PCW hours. The patient has 24-hour care needs and therefore a test based assessment should not have been utilized to calculate hours. The request increase in PCW services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, PCW services 12 hours/day, 7 days/week, to total 84 hours/week 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: Overturned

Diagnosis: Premature birth, spastic quadriplegic cerebral palsy, and core hypotonia. 
Treatment: Durable Medical Equipment (wheelchair and accessories: K0005x1, E2213x2, K0038x2, E0971x2, E2613x1, E0956x1, E2607x1, E0955x1, E0960x1, E0952x2)
The insurer denied: Durable Medical Equipment (wheelchair and accessories: K0005x1, E2213x2, K0038x2, E0971x2, E2613x1, E0956x1, E2607x1, E0955x1, E0960x1, E0952x2).
The denial is overturned.

The patient is a female preschool child with a medical history significant for premature birth born at thirty-five weeks' gestation, spastic quadriplegic cerebral palsy, and core hypotonia. She will be attending kindergarten in the fall of this year, riding the school bus to and from school. Because she has decreased trunk/core strength, decreased balance/postural control, decreased head control, and abnormal tone throughout her body, she requires a wheelchair for safe bus transportation and traversing the school hallways. She also requires support for community and long-distance mobility because of fatigue and instability. She does not require the wheelchair for mobility at home. The family currently uses a baby stroller in the community, but the child is outgrowing the stroller and there is no option for independent mobility, because the stroller requires pushing. The wheelchair that has been recommended builds in a significant growth allowance, is lightweight and folds to allow for storage and transportation and is lightweight enough that the child can easily propel herself independently.

The requested durable medical equipment is medically necessary.

The American Academy of Pediatrics has published guidelines for home care of infants, children, and adolescents with chronic disease: "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1)

This young child has mobility challenges as a result of her quadriplegia, spasticity, and hypotonia. She is able to maneuver around her house by scooting and crawling but lacks the stability and stamina to safely negotiate the school bus, school hallways, and community. She is outgrowing the baby stroller that is currently being used. She is not learning independent mobility skills being pushed around in a stroller. The requested wheelchair with accessories is medically necessary and appropriate for this child to allow for safe mobility on the bus, at school, and in the community. It will also provide the child with an opportunity to develop age-appropriate independence.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept procedure 
The health plan denied: Intracept procedure
The denial is: Upheld

The patient is a male with complaints of low back pain. The patient is noted to have peripheral polyneuropathy and other musculoskeletal problems, including old compression fractures. The patient has chronic low back pain, predominately axial. The patient was diagnosed with discogenic low back pain with significant Modic changes. Magnetic resonance imaging (MRI) of the lumbar spine demonstrates multilevel degenerative changes. Medications include gabapentin. The patient's diagnoses include discogenic low back pain, vertebral genic low back pain. Prior treatments have included multiple lumbar injections. There is a request for Intracept procedure.

The health plan's determination is upheld.

The proposed health service or treatment Intracept 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 has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Given the above, the proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept procedure 
The health plan denied: Intracept procedure
The denial is: Upheld

The patient is a male diagnosed with vertebrogenic pain and lumbar intervertebral disc degeneration. Records indicate the patient was recommended to undergo the Intracept Procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance plan. The subject under review is whether the proposed Intracept procedure is likely to be more beneficial for the patient than any standard treatment.

The health plan's determination is upheld.

There is no evidence to suggest that the proposed health service or treatment Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This treatment is not currently considered standard of care in the general medical community. There is a lack of high-grade evidence and large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure. There is no evidence to suggest that the proposed health service or treatment Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept procedure 
The health plan denied: Intracept procedure
The denial is: Overturned.

This patient is a male who has a chief complaint of axial back pain. He has a medical history of peripheral polyneuropathy and a thoracic compression fracture. His back pain is in the midline at lumbosacral region. This patient has symptoms of peripheral neuropathy in the lower extremities, but no radicular pain. His prior treatments including epidural injections and lumbar medical branch nerve blocks failed to provide adequate improvement. Magnetic resonance imaging (MRI) revealed Modic type 1 and 2 changes at lumbar (L)4-5 and L5-sacral (S)1 levels. This patient was recommended to have basivertebral nerve radiofrequency ablation for his persistent low back pain.
The issue is whether basivertebral nerve radiofrequency ablation (Intracept procedure) is likely to be more beneficial for this patient's persistent back pain based on the available clinical findings and current studies.

The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient has persistent back pain consistent with L4-5 and L5-S1 degenerative endplate changes. He had failed extensive treatments including epidural injections and facet blocks. Further interventions are required to improve his pain and functional level. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs [NSAIDs], opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, Intracept procedure is likely to be more beneficial than any standard treatment for this patient's condition. It is the appropriate next step intervention.