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


Diagnosis: cerebral vascular accident
Treatment: home health care
The insurer denied Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Monday through Sunday) in Split Shifts. The health plan's determination is overturned. 

The patient is a male with past medical history of prostate cancer, benign prostatic hyperplasia (BPH), chronic kidney disease, hypertension, cerebrovascular accident (CVA), Parkinson's disease, urinary incontinence, duodenal ulcer, chronic blood loss anemia, and glaucoma who had been assigned PCA (personal care assistant) services and had an updated assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, bathing, walking and locomotion while extensive assistance with tasks of managing finances, managing medication, phone use, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use. 

Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Monday through Sunday) in Split Shifts is medically necessary for this patient.
There is documentation of worsening functional status by his medical providers and by the noted assistance needs on the assessment. The patient requires extensive assistance with transfer toilet, toilet use, walking, and locomotion. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has no informal helper. The patient's geriatrician documented the need for overnight care including turning and repositioning every 2 hours to prevent skin breakdown. The patient's overnight care needs would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The 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, PCA services 24 hours/day, split-shifts, 7 days/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 his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Advanced Imaging. 
The insurer denied computed tomography (CT) , special picture of the head or brain without contrast (dye). 
The denial is overturned. 

The patient is a male with a history of a right middle cerebral artery (MCA)/posterior cerebral artery (PCA) stroke and hydrocephalus. The patient has a ventriculoperitoneal (VP) shunt that was placed previously. The patient was admitted to the hospital for hypernatremia, hypovolemia and dehydration. The patient had mental status changes and possible seizure activity. The patient had a computed tomography (CT) of the head while hospitalized. The provider is requesting a repeat CT scan which is the subject of this review.

The health plan's determination is overturned.

A repeat CT of the head would be medically necessary. The hemorrhagic stroke had not completely resolved, and its evolution would need to be monitored. Additionally, the was evidence of slight dilatation of a frontal horn that would need follow up to evaluate for possible VP shunt malfunction.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied Home Care/Personal Care HHC - Personal Care Aide-Live-in per diem remain at 24 hrs. per day. 
The denial is upheld.

The patient is a female with past medical history significant for atrial fibrillation, osteoarthritis, dementia, depression, anxiety disorder, lower extremity edema, hypertension, hyperlipidemia, obesity and generalized debility.
This review is for the medical necessity of home care/personal care home health care (HHC) live-in per diem 24 hours per day. The patient had been decreased to 52 hours a week. Additional services were denied based upon medical necessity.
The subject under review is the medial necessity for an increase in home care/personal care home health care (HHC) - personal care aide live in per diem to 24 hours a day.

The health plan's determination is upheld.

The requested health service is not medically necessary for this patient.
Services were denied by her insurance stating the following. There is no letter of medical necessity provided with this appeal. Based on the  comprehensive nurse's assessments the patient is non-self-directing, members function has decreased, now needing limited, extensive, maximum total assistance with all activities of daily living. She has fallen and been evaluated in the emergency department and urgent care center in the last 60 days but has not been hospitalized. Her medical diagnoses and medications have been minimally changed. The member has no evidence needing 24 hour per day live in caregiver. She has no nighttime needs. Specifically, she has no pressure ulcers, does not wander and has no sleep disturbances. Given a decrease in her function it is medically necessary to provide this member with 52 hours a week of services.
There is a Physician's letter of medical necessity statement states that the patient should not be left alone and needs 24 hour 7 days a week observation and assistance. Walking, she was noted to need limited assistance, toilet use, she needed limited assistance. Uniform Assessment System (UAS) and the tasking tool noted a need for 22 hours a week of services.
There are no specific documented nocturnal needs/ADLs which cannot be addressed appropriately in the allotted time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status; vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with a history of polysubstance abuse, GERD (gastroesophageal reflux disease) and asthma. She had been admitted to detoxification for alcohol and opiate withdrawal, and she presented with altered mental status and vomiting. She had been started on librium and Suboxone.

The patient's Vital Signs were as follows: Temperature = 37, Pulse = 79, Respiratory Rate = 18, Blood Pressure = 102/67, Pulse oxygenation 98%. The patient's exam was unremarkable. Her Labs were as follows: White blood cells (WBC) = 8.55, Hemoglobin/Hematocrit (H/H) = 10.8/34.2, Platelet (Plt) = 199, Sodium (Na) = 141, Potassium (K) = 4.1, Blood urea nitrogen/Creatinine (BUN/Cr) = 13/.82, Glucose = 117, Ammonia = 25. Chest x-ray was normal.

The patient was admitted. Oral antibiotics were started. Gastroenterology consultation noted the patient was alert and oriented. Recommended to continue lactulose.

No, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient presented from detoxification with altered mental status and vomiting. On day of admission, she was noted to be alert and oriented. The patient was hemodynamically stable and afebrile. She had normal oxygenation. She did not have severe electrolyte abnormalities or renal insufficiency. Her ammonia level was normal. No obvious source of infection was identified. The patient was clinically stable. Oral antibiotics were started. The patient's severity of illness did not require inpatient admission. She did not receive intervention that required inpatient admission. Inpatient Hospital Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever and hypotension.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is a male with past medical history significant for atrial fibrillation, status post ablation who presented to the emergency department with complaints of fever with cold like symptoms and nausea. 

Vitals on presentation included a temperature of 102.8 Fahrenheit (F), blood pressure 124/95, pulse 116, respiratory rate 17, oxygen (O2) 98% on room air. Laboratory results showed white blood cell count (WBC) 18.8, hemoglobin 15.1, hematocrit 45.5, sodium 126, creatinine 1.3, and glucose 53. Chest x-ray was negative.

The patient was admitted for fever and hypotension. He was empirically started on broad-spectrum antibiotics (vancomycin and ceftriaxone). Cultures were obtained but remained negative. The patient improved clinically and remained hemodynamically stable. He was discharged to continue oral antibiotics (cefdinir) as an outpatient management. 

According to medical records, this patient presented with high fevers (102.8 F), tachycardia, and hypotension. Laboratory results revealed significant leukocytosis (18.8). Based on above findings, the patient was at high risk for sepsis and met criteria for hospital admission for administration of antibiotics and further evaluation. 

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This male was hospitalized for evaluation of atypical, right-sided, persistent chest pain times one week (x1) in the setting of known coronary artery disease (CAD) and an abnormal stress echocardiogram. He was sent to the emergency department (ED) by his cardiologist and he had an emergent cardiac catheterization with coronary angiography showing severe left anterior descending (LAD) coronary artery disease. He underwent successful percutaneous coronary intervention (PCI). The patient's past medical history (PMH) is significant for known coronary artery disease (CAD), current smoking, hypertension (HTN), hyperlipidemia (HLP) and prediabetes. The patient's vitals were stable. There were no procedural-related complications, he was admitted as inpatient status to the hospital for post-procedure care and he was discharged to home on the same day. This is an appeal of the denied claim of the requested acute inpatient hospital stay.

No, the proposed treatment was not medically necessary.
Based on the peer reviewed medical literature, including the 22nd Edition Milliman Care Guidelines: Angioplasty, Percutaneous Coronary Intervention ORG: W0120 (ISC), criteria for admission are not met. The goal length of stay is ambulatory. Inpatient stay may be needed for percutaneous coronary intervention (PCI) for unstable angina after acute myocardial infarction (MI), but none was documented. In this particular case, the patient underwent left heart catheterization (LHC) with percutaneous coronary intervention (PCI). The submitted information does not support the medical necessity for admission after his successful and uncomplicated coronary intervention. Percutaneous coronary intervention (PCI) procedures are routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like acute myocardial infarct (AMI), cerebral vascular accident (CVA), contrast nephropathy, acutely decompensated congestive heart failure (CHF), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery or retroperitoneal hematoma, extravascular procedural complications such as, pericardial effusion, or cardiac tamponade requiring pericardiocentesis or surgery, urgent or emergent coronary artery bypass grafting (CABG) surgery, patient requiring glycoprotein receptor inhibitors for use including complex lesions and threatened or actual vessel closure or other medical instability or acute care needs that would require acute inpatient management. Therefore, the proposed treatment was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Right breast DCIS (ductal carcinoma in situ)
Treatment: OncotypeDX Breast DCIS Assay Genetic Testing (0045U)
The insurer denied the OncotypeDX Breast DCIS Assay Genetic Testing (0045U).
The denial is upheld.

The patient is a female with DCIS (ductal carcinoma in situ). Her provider performed OncotypeDX testing.

No, the health plan should not cover the OncotypeDX Breast DCIS Assay Genetic Testing (0045U).

No, the OncotypeDX Breast DCIS Assay Genetic Testing (0045U) is not more beneficial.

The benefit of RT (radiation therapy) for DCIS (was shown in a meta-analysis of RT compared with no further treatment following lumpectomy. Compared with lumpectomy alone, RT resulted in a reduction in the risk of all ipsilateral breast events. This translated into a number needed to treat of nine women to prevent one ipsilateral breast recurrence. As in the treatment of invasive breast cancer, the standard of care for patients undergoing BCT (breast-conserving therapy) is to deliver adjuvant whole-breast radiation therapy (WBRT), typically within eight weeks of surgery. Conventionally dosed WBRT consists of 1.8 to 2 Gy (gray) daily fractions over 4.5 to 5 weeks to a total dose of 45 to 50 Gy, often followed by a boost to the surgical bed.

RT reduces the odds of in-breast recurrence but likely does not change the odds of distant recurrence or decrease mortality. For patients with low-risk disease that has been fully resected with widely negative margins, the absolute reduction of in-breast recurrence may not be large enough to justify the risks associated with RT. In such patients, it is reasonable to omit RT, especially in the setting of comorbidity, advanced age, or patient preference. Results from the NSABP (National Surgical Adjuvant Breast and Bowel Project) B-17 trial have been used to argue for RT in all women who undergo lumpectomy for pure DCIS.

Gene expression analysis such as the OncotypeDX DCIS recurrence score has been studied as a tool for identification of patients for whom post-lumpectomy RT may reasonably be omitted, but data regarding its utility are still limited. At this time, the NCCN (National Comprehensive Cancer Network) does not support the routine use of this testing to guide management in women with DCIS and feels that universally all women with DCIS should be offered adjuvant radiation.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Right breast DCIS (ductal carcinoma in situ)
Treatment: OncotypeDX Breast DCIS Assay Genetic Testing (0045U)
The insurer denied the OncotypeDX Breast DCIS Assay Genetic Testing (0045U).
The denial is upheld.

The patient is a woman diagnosed with right breast DCIS (ductal carcinoma in situ),
ER/PR (estrogen receptor/progesterone receptor) positive, measuring 7 mm
(millimeters). OncotypeDX DCIS testing was performed.

No, the health plan should not cover the OncotypeDX Breast DCIS Assay Genetic Testing (0045U).

OncotypeDX DCIS is a gene expression test that is done to help determine whether radiation can be safely omitted following resection of DCIS. As of the present time, there is no evidence showing that use of this test can clearly improve health outcomes. At the present time, it is not considered a routine standard component of the evaluation of women diagnosed with DCIS. NCCN (National Comprehensive Cancer Network) guidelines do not endorse use of OncotypeDX DCIS testing as a standard test to help determine whether radiotherapy should be given following resection.

No, the OncotypeDX Breast DCIS Assay Genetic Testing (0045U) is not more beneficial.

As above, there is no evidence showing that use of this test can improve health
outcomes. Therefore, it is not more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 

The insurer denied Intracept procedure. 
The denial is overturned. 

The patient is a female who has chronic low back pain. Her pain occurred after a motor vehicle accident. Pain level ranges from 5/10 to 10/10. The pain is aggravated by prolonged sitting and standing. Her low back pain persisted despite epidural injections, trigger point injections, physical therapy (PT), chiropractic care, non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxers. Physical exam (PE) was unremarkable except restricted range of motion (ROM) of lumbar spine. Magnetic resonance imaging (MRI) revealed Modic changes in lumbar (L)5 and sacral (S)1 vertebral bodies. This patient was recommended to have the Intracept procedure. 
The issue is whether this Intracept procedure is an appropriate treatment option for this patient's persistent back pain based on the available clinical findings and current studies, and whether it would be more beneficial for the patient than standard treatments. 

The proposed Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's persistent low back pain. 
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 L5-S1 degenerative endplate changes. She had failed epidural injections, trigger point injections, PT, chiropractic care, NSAIDs and muscle relaxers. Her pain is severe ranging from 5/10 to 10/10. Further interventions are necessary to improve her pain and functionality. Other potential treatment options are long-term use of medications (NSAIDs, opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the Intracept procedure is the appropriate next step intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 

The insurer denied Intracept procedure. 
The denial is upheld. 

The patient is a female with complaints of low back pain. The patient continues to have low back pain. The patient completed physical therapy, but the pain continued. The patient is still doing home stretching. The patient also started chiropractic care. The patient was using non-steroidal anti-inflammatory drugs (NSAIDs). The pain is rated 6-7 out of 10, intermittent, and improved by lying down and heat. The physical exam demonstrated lumbar spine restricted lumbar range of motion, pain with lumbar flexion, straight leg raise negative bilaterally. The patient's diagnoses include vertebral genic low back pain. She has had prior lumbar injections. Magnetic resonance imaging (MRI) of the lumbar spine reported disc bulging with left central disc herniation at lumbar (L)3-4, multilevel disc degeneration. The subject under review is whether the Intracept procedure is likely to be more beneficial for this patient than any standard treatment. 

The proposed Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition. 

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 condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Erosive gastritis. 
Treatment: Esophagogastroduodenoscopy (EGD) (procedure code 43239). 

The insurer denied coverage for esophagogastroduodenoscopy (EGD) (procedure code 43239). 

The denial is overturned. 

The patient was having epigastric pain. He had been on Omeprazole, but the pain persisted. He underwent an upper GI (gastrointestinal) endoscopy and erosive gastritis as well as duodenitis were found. The biopsies confirmed the presence of erosive gastritis. 

MCG (Milliman care guideline) ACG: A-0203 lists indications for upper GI endoscopy. Dyspepsia along with an associated risk factor is listed as an indication for the procedure. Both age and failure of medical therapy, such as a poor response to a PPI (proton pump inhibitor), are indications for the procedure. 

This patient had epigastric pain and had not responded to a PPI. These associated risk factors meet the MCG criteria as an indication to have an endoscopy. He was found to have erosive gastritis that was confirmed on the biopsies. The health care plan did not act reasonably or with sound medical judgment. The endoscopy was medically necessary. 

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

The insurer's denial of coverage for diagnostic esophagogastroduodenoscopy (EGD) (procedure code 43239), is overturned. Medical Necessity is substantiated.