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

Diagnosis: Diabetes, depression and Alzheimer's dementia
Treatment: Consumer Directed Personal Assistant Services (CDPAS) 84 hours per week
The insurer denied coverage for Consumer Directed Personal Assistant Services (CDPAS) 84 hours per week.
The denial is overturned.

This is an elderly patient with chronic medical problems including diabetes, depression and Alzheimer's dementia. She was admitted to the hospital for pneumonia and COVID-19 (2019 Novel Coronavirus). She was discharged from the hospital and readmitted the same day due to a fall at home sustaining a left hip fracture. The patient is currently receiving 38 hours/week CDPAS and requesting an increase to 84 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." She requires maximal assistance for bathing, lower body dressing, locomotion and toilet transfers/use. She is frequently bladder incontinent and infrequently bowel incontinent. Extensive assistance is needed for personal hygiene, upper body dressing and bed mobility. Her cognitive and functional abilities have significantly declined compared to the UAS report. The UAS report specifically indicates her "mental, clinical status has been severely deteriorating." The combination of the patient's cognitive and functional decline supports an increase in CDPAS. Her condition and functional needs are at a level and unpredictable as to require the requested 84 hours per week. Based on the enclosed documents reviewed, the patient's health and safety is more appropriately provided and maintained by increasing the CDPAS to 84 hours per week.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested increase CDPAS 84 hours per week is medically necessary.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Consumer Directed Personal Assistant Services (CDPAS) 84 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, history of stroke with right sided weakness
Treatment: Social daycare services (for a total of 1 day/week)
The insurer denied the social daycare services (for a total of 1 day/week).
The denial is upheld.

The patient is an elderly female. The patient lives alone. She has impaired cognitive skills and memory problems. She is alert and oriented times three. She has total dependence with ordinary housework and needs maximal assistance with managing finances, managing medications, shopping, and meal preparation. She needs maximal to extensive assistance with activities of daily living (ADLs) due to osteoarthritis, osteoporosis, history of stroke, and residual right sided weakness. The patient is frequently urine incontinent.

The patient is currently receiving 7 hours/day, 6 days/week and 4 hours/day, 1 day/week (totaling 46 hours/week) of personal care aide (PCA) with social daycare (SDC) services 1 day/week.  The request is for social daycare services (for a total of 1 day/week).

The proposed treatment, social daycare services 1 day/week, is not medically necessary.

The patient is currently receiving PCA services 7 hours/day, 6 days/week and 4 hours/day, 1 day/week (totaling 46 hours/week). This service includes personal care services (PCS) including assistance with ADLs and instrumental activities of daily living (such as shopping, housekeeping, and meal preparation). The request for social daycare services (for a total of 1 day/week) is not indicated as the social daycare services would overlap with the patient's PCS. The amount of PCS the patient receives will not allow enough time during the day to receive the current number of social daycare services requested (1 day).  The health plan's denial is consistent with guidelines and standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept procedure
The insurer denied the Intracept procedure
The denial is upheld

The patient is a male with low back pain. He takes NSAIDs (nonsteroidal anti-inflammatory drugs) and tizanidine and uses ZTlido (lidocaine) patch for pain. His pain score is 4-6/10. MRI (magnetic resonance imaging) shows disc bulges at L3-4 (third lumbar spine vertebra-fourth lumbar spine vertebra) and L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) as well as Schmorl's nodes at L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra).

At L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) there is 1-2mm (millimeter) anteriolisthesis as well as disc bulge and facet hypertrophy. Scoliosis of the lumbar spine to the left is also noted. Request for L3 (third lumbar spine vertebra) and L4 (fourth lumbar spine vertebra) Intracept procedure was denied coverage by the health plan as experimental/investigational.

No, the health plan should not cover the Intrcept procedure for this patient.
A service is considered medically appropriate when it meets the accepted standards of medicine and is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms. There must be peer-reviewed medical literature based on scientific data that shows a treatment is safe and effective for treating or diagnosing a medical condition. It must be necessary to meet patients basic health needs and it must be correct for the diagnosis.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

The patient does not meet inclusion and exclusion criteria in the current published studies. As such, the Health plan should not cover the Intracept procedure for this patient.

No, the requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease.
Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on type 1 or type 2 Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. The patient does not meet inclusion and exclusion criteria in the current published studies. The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept procedure
The insurer denied the Intracept procedure
The denial is upheld

The patient is a male with chronic low back pain in whom an Intracept procedure has been requested.  The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), home exercise plan, epidural steroid injections, facet injections/medial branch blocks.  The patient has failed multiple medications including potent opiate medications. MRI  (magnetic resonance imaging) shows Modic changes at L4-5 (fourth lumbar spine vertebra-fifth lumbarspine vertebra). Physical exam does not reveal any neurological injury.

No, the health plan should not cover the Intracept procedure.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown effective in RCT (randomized controlled trial) with 5 year results.

However, the patient in this case has not failed or attempted sacroiliac joint injections, which are common causes of axial low back pain, and there is no documentation on the results to the requested RFA (radiofrequency ablation). The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not likely to be more beneficial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld.

Based on the clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department. The patient underwent an uneventful laparoscopic appendectomy. There were no reported complications related to the procedure. An outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation. [1-2]

The hospital stay was not medically necessary. The patient presented to the emergency department with a three-day history of right lower abdominal pain. There was no associated vomiting or diarrhea. The patient had an MRI (magnetic resonance imaging) that demonstrated nonperforated acute appendicitis. The White blood cell count was 8.4. The patient underwent an uneventful laparoscopic appendectomy. There were no complications related to the procedure itself. The patient was noted to have a bronchospasm upon extubation. The patient was noted to have increased pain on postoperative day 1 but oral pain medications continued. The diet was advanced as tolerated. Admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., COPD (chronic obstructive pulmonary disease), chronic heart failure), or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care. Peer-reviewed literature also indicates that a laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis. Therefore, the requested hospital stay is not necessary. Observation status would have been sufficient. 

The insurer's denial of coverage for the impatient emergency admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Squamous cell carcinoma
Treatment: Inpatient admission 
The insurer denied: Inpatient admission
The denial is upheld

The patient is an adult female with a diagnosis of squamous cell carcinoma. She underwent an uncomplicated right radical vulvectomy with bilateral inguinofemoral lymph node dissection. The procedure was uncomplicated with a blood loss of 300 cc (cubic centimeters). Right lower quadrant and left lower quadrant drains were placed. The patient was admitted to the inpatient service. The patient recovered uneventfully. She was afebrile overnight with normal vital signs. The Foley catheter was removed the next day. On the day of discharge, the patient was again afebrile with vital signs stable. She was tolerating a normal diet, ambulating freely, passing flatus and her pain well-controlled. 

The inpatient admission was not medically necessary.

The medical records were thoroughly reviewed. The patient underwent a procedure that was uncomplicated with a low blood loss. The procedure was not intraperitoneal, therefore there was no concern for an intra-abdominal complication. The patient had an uneventful recovery. She was afebrile overnight with normal vital signs. On the day of discharge, the patient was again afebrile with vital signs stable. She was tolerating a normal diet, ambulating freely, passing flatus and her pain well-controlled. The patient could have been managed postoperatively in a setting with a lower level of care. Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Zygomatic/malar complex fracture status post fall
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld

The patient is an adult male who sustained a zygomatic/malar complex fracture seven days prior to his presentation to the Emergency Department. The patient was admitted as an inpatient from the ED (emergency department) in order to have an open reduction with internal fixation performed. The patient's hospital course included the surgical procedure and anesthesia. The patient was discharged on the day following surgery. The inpatient claim was denied coverage by the health plan, as it was felt that the patient should have been treated as an outpatient / observation. This denial is being appealed.

The inpatient admission was not medically necessary.

The patient had a displaced fracture of the zygomatic/malar complex, and an open reduction with internal fixation was indicated. However, none of the reviewed medical records, including the operative note and post-surgical notes give any indication that an inpatient admission was needed. The patient could have been treated on an observation basis. Current literature and standard of care support treatment of this type of surgery as an observation stay.

Therefore, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral thyroid nodules
Treatment: Surgery (thyroidectomy- 60252 x 1)
The insurer denied: Surgery (thyroidectomy- 60252 x 1)
The denial is upheld.

The patient is an adult female with a history of a bilateral thyroid nodules with a dominant left thyroid nodule that has increased in size. FNA (fine needle aspiration) is reported as benign. The left nodule is reported as growing and causing the patient to have throat problems. The provider is requesting a thyroidectomy, code 60252. The request was previously denied coverage by the health plan, and the provider is appealing the denial.

The requested surgery (thyroidectomy- 60252 x 1) is not medically necessary.
The provider is requesting a thyroid lobectomy for an enlarging left thyroid nodule as discussed in the provider surgical plan. FNA (fine needle aspiration) is benign for this nodule. However, the CPT (Current Procedural Terminology) code that has been requested, 60252, is for a more extensive procedure which is for malignancy. Therefore, based on the information provided, the medical necessity of the CPT (Current Procedural Terminology) code 60252 cannot be confirmed for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dyspnea, Pulmonary Embolism.
Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a history of deep vein thrombosis, pulmonary embolism provoked by knee surgery and he underwent mechanical thrombectomy, who recently discontinued his anticoagulation 3 months prior to admission. The presenting complaints were dyspnea on exertion and leg pain for a few days. On arrival to the emergency department the patient's vital signs were a blood pressure of 127/75, heart rate 87, respiratory rate 20, with an oxygen saturation of 97% on room air. The physical exam was unremarkable. Lab results were unremarkable. Radiology was notable for an extensive deep vein thrombosis (DVT) in the right lower extremity, pulmonary embolism seen which could represent an acute pulmonary embolism (PE) or acute on chronic PE. A six minute walk test was performed without evidence of ambulatory hypoxia. The patient was started on enoxaparin and transitioned to a oral anticoagulant. A transthoracic echocardiogram was performed without evidence of right heart strain. A hypercoagulability workup was initiated. The patient's dyspnea improved and he was discharged home on lifelong anticoagulation.
At issue is the medical necessity of an inpatient stay.

An inpatient stay was medically necessary for this patient.
The patient presented with acute dyspnea and a new acute pulmonary embolism. A thorough workup to risk-stratify the patient was initiated, which included cardiac biomarker testing and transthoracic echocardiography. These results eventually helped to place the patient into a low-risk category allowing for safe discharge home with an anticoagulant. Since pulmonary embolism is a heterogeneous condition in which the risk for sudden death and decompensation is possible, close monitoring at an inpatient level of care is the safest pathway until enough data for risk stratification is collected. Although some patients can undergo this workup quickly and be discharged home from the emergency department, common pulmonary embolism scoring tools such as the Pulmonary Embolism Severity Index excluded patients who already have a diagnosis of pulmonary embolism, as this patient did. Clear risk stratification is not as easy for these patients, and their outcomes are less clear, so more reliance on clinical decision making is needed. This patient had a PE within the previous 8 months and it was severe enough to require mechanical thrombectomy at that time. An inpatient level of service represented the safest path to monitor the patient's symptoms for decompensation, complete data collection for risk stratification, and improve the patient's dyspnea to allow him to return home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 braces.
The insurer denied D8080 braces.
The denial is overturned.

The patient is a male. He has a Class II malocclusion with protrusive maxillary incisors. He has 6 millimeter (mm) overjet and 6mm overbite. Teeth 8 and 9 have a history of trauma and have large restorations. He is treatment planned for orthodontics to correct this malocclusion which was denied by the health plan based on lack of medical necessity.

The health plan's determination is overturned. Braces are medically necessary for this patient.

Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma.1 Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. This is particularly important for this patient since teeth 8 and 9 have already been fractured once. If one is traumatized again, it will likely result in more significant tooth damage. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Full Hospital Admission
The insurer denied coverage for full hospital admission.
The denial is upheld.

This is a male who presented to the hospital complaining of chest pain and lightheadedness. His past medical history was significant for known coronary artery disease and percutaneous coronary intervention to the left circumflex artery one month earlier. Repeat catheterization for chest pain revealed patent stents. Upon arrival to the hospital, vital signs were stable with blood pressure (BP) 116/73, and heart rate 77 beats per minute. Physical exam revealed no abnormal findings. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm without ischemic ST (interval on EKG) or T (interval on EKG) wave abnormalities. Serum troponin levels were not elevated, and the patient was discharged the following day with cardiology follow up.

The patient's pretest probability of coronary artery disease is high (1). Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score, he was considered intermediate risk (5 points) (2). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (3). Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (4, 5). They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day MI rates as those admitted to the hospital (5). 

Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care. 

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

The insurer's denial of coverage for full hospital admission is upheld. Medical Necessity is not substantiated.