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

Diagnosis: low back pain

Treatment: pain injection (64635 x 1, 64636 x 1)

The insurer denied coverage for pain injection (64635 x 1, 64636 x 1)

The denial is overturned

This is an adult female with chronic axial low back pain. She had Right Lumbar (L) L3/L4, L4/L5 and L5/S1 radiofrequency ablation (RFA) of the medial branches on 5/13/22 and had 98% pain relief for 7 months.  The request is to repeat the radiofrequency ablation.	

Manchikanti et al (1) published evidence based guidelines for performing facet blocks and concluded:

The level of evidence is II with moderate strength of recommendation for lumbar radiofrequency ablation with inclusion of 11 relevant randomized controlled trials (RCTs) with 2 negative studies and 4 studies with long-term improvement.

Similarly, Cohen et al (2) published a consensus guideline which also supports the performance of repeat radiofrequency ablation in this patient. 

The request is medically reasonable and 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 pain injection (64635 x 1, 64636 x 1) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with past medical history of renal transplant who presents to the emergency department complaining of abdominal pain. He reports having nausea and vomiting after a meal. Pain is located in his epigastric area. A computed tomography (CT) abdomen/pelvis showed a dilated gallbladder which appears thick walled with surrounding pericholecystic fluid and stranding. A Right upper quadrant ultrasound showed no evidence of gallstones. No evidence of gallbladder wall thickening or pericholecystic fluid was noted. Sonographic Murphy's sign was negative. 

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient developed abdominal pain and was admitted as an inpatient for evaluation. Work up consisted of imaging studies and laboratory studies. There was no evidence of acute cholecystitis based on ultrasound and laboratory studies. He did not undergo any surgical intervention and he was discharged the following day. A lower level of care would have been sufficient for this patient's care.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home health care

Diagnosis: Alzheimer's disease
Treatment: Home health care
The insurer denied Consumer Directed Personal Assistance Services, a Total of 84 Hours per Week. The health plan's determination is overturned. 

This is a case review for a female with medical history notable for Alzheimer's disease. The patient's neurologist provided a letter of support for this appeal. The letter states that the patient scored a 7/30 on the mini-mental state exam (MMSE) in February, and that score has now dropped to 2/30. The patient cannot shower, dress, or toilet without assistance. She has wandering behaviors at night. Given the progressive neurodegenerative diagnosis of Alzheimer's disease, the physician expects that the patient's personal care needs will only increase. He requests an increase in personal care hours to meet her needs.

The requested Consumer Directed Personal Assistance Services, a Total of 84 Hours per Week is medically necessary for this patient.

The patient's dementia is rapidly progressing and her cognitive and functional status is having a commensurate decline. She is unable to direct any of her own care. The Uniform Assessment System (UAS) demonstrates that the patient requires hands on assistance with most activities of daily living (ADL) and all Instrumental activities of daily living (IADL), and documentation from the patient's physicians and family indicates that her functional status is actually worse than what is portrayed in the UAS. The patient's care needs can be expected to be continuous and unscheduled throughout the day. Therefore, the requested increase in personal care hours is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: lower back pain
Treatment: pain injections (64483 x 1, 64484 x 1)

The insurer denied coverage for pain injections (64483 x 1, 64484 x 1)

The denial is overturned.

This is an adult with a history of lower back pain. The patient had a spinal cord stimulator removed. The patient had an epidural steroid injection (ESI) and reported 100% relief. The patient was treated with physical therapy (PT). The request was to repeat the epidural steroid injection (ESI). 

The procedure is medically reasonable and necessary.

Kwak et al  evaluated the long-term outcomes of Transforaminal Epidural Steroid Injections (TFESI) in patients with lumbosacral radicular pain due to a Herniated Lumbar Disk (HLD) by the location, type, and size of the HLD.

In total, 114 patients who received the initial TFESI at least 4 years ago completed a telephone interview. They investigated the presence of radicular pain, degree of current pain, current pain medications and TFESIs, additional TFESIs, progression to surgery, and trouble in performing daily life activities and occupational job duties. They classified the included patients by the location, type, and size of the HLD, and evaluated whether these factors affected the long-term outcomes of TFESI.

At least 4 years after the initial TFESI, radicular pain was completely resolved in 45% of the patients. However, 30% patients were on oral painkillers or repetitive TFESIs or had undergone surgery and 15% had difficulty in performing daily life activities and occupational job duties. A larger number of patients with extruded lumbar disc herniation required additional TFESIs than those with protruded lumbar disc herniation. Apart from this, the outcomes did not significantly differ by the location, type, and size of the HLD. [1]

A Cochrane review found moderate-quality evidence that epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain and disability at short-term follow-up. The treatment effects were small, however, and may not be considered clinically important by patients and clinicians. We identified mostly minor adverse events (e.g., headache, accidental dural punctures, worsening pain) after epidural corticosteroid injections and placebo injections and very low-quality evidence that there is no difference between groups. Long term follow-up (greater than 12 months) found modest effects. [2]

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 pain injections (64483 x 1, 64484 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient Admission. 

The insurer denied the Inpatient Admission. 
The determination is upheld. 

The patient is an adult male who was self-referred and was admitted to inpatient rehabilitation substance use disorder treatment for stimulant (crack cocaine) use disorders. The patient was using up to $50 worth of crack cocaine daily. The patient was also tobacco dependent at one pack per day with 22 pack years. His referral was prompted by his desire to stop using substances of abuse after longstanding use and a decline in functioning with homelessness and unemployment. He had a history of multiple past substance use disorder treatment episodes with multiple past detoxification treatments and rehabilitation treatment. 
The mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. His mood was anxious with congruent affect. The patient's thought content included no morbid thoughts. He had no evidence for cognitive impairment, perceptual disturbance, mood disturbance or psychosis. Insight was limited with impaired judgment due to the addiction. He had sleep disturbance with insomnia. 
The patient easily transitioned to rehabilitation treatment. He actively participated in individual, group, and educational sessions. He was prescribed vitamins and comfort medications with the availability of nicotine replacement therapy. He received consultations for general medical conditions and psychiatric evaluation without complication. 
Discharge planning occurred that included recommendation for continued residential aftercare upon completion of the program. The patient was cooperative and engaged throughout his inpatient stay. 

At issue is the medical necessity of an inpatient admission.

The requested health service/treatment of inpatient admission was not medically necessary for this patient. The inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care, as noted above. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for his cocaine use disorder. 

There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment. Thus, the requested benefit of inpatient substance use disorder rehabilitation services was not medically necessary for this patient. This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the published guidelines and the scientific literature, referenced below together with the application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Surgery (outpatient procedure - 0275T x 1)
The insurer denied: Surgery (outpatient procedure - 0275T x 1)
The denial is overturned.

The patient is an adult male with a history of chronic low back pain due to lumbar stenosis. He has failed conservative measures including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, physician-directed home exercise program, spinal injections, etc., to no 
avail. The request by the treating physician is for a minimally invasive lumbar decompression/percutaneous image-guided lumbar decompression (MILD/PILD) procedure to be performed at L4-5 level.

The requested health service is medically necessary.

According to Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment, there is Level 1 evidence for Percutaneous image-guided Lumbar Decompression as superior to lumbar epidural steroid injections consisting of five controlled prospective studies, and 17 other retrospective studies, case series, meta-analyses, etc., published in peer-reviewed journals. The minimally invasive lumbar decompression/percutaneous image-guided lumbar decompression (MILD/PILD) procedure has been shown to be at least as effective for other pain procedures. It is less invasive and effective in improving pain. As such, it is achievable in standard conditions of medical practice as published in multiple peer-reviewed journals, some of which are listed in the 
references below. Therefore, the proposed Percutaneous image-guided Lumbar Decompression (PLID) is medically necessary for this patient with lumbar stenosis, as it is United States Food and Drug Administration (FDA) approved for spinal decompression in spinal stenosis and not unproven.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enlarged tonsils
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a female child with medical history significant for recurrent upper respiratory infections and enlarged tonsils, who underwent tonsillectomy and adenoidectomy under general anesthesia. The surgery was uneventful but throughout the case and post-operatively, she remained tachycardic. Her recovery from anesthesia was also delayed, requiring placement of a non-rebreather oxygen mask. She was admitted to the pediatric floor for monitoring and observation. 

Acute inpatient admission was not medically necessary.

Adenotonsillectomy is a common surgical procedure in children, considered to be painful, particularly in the early post-operative period. Up to a week post-operative, children continue to complain of significant discomfort. Patients frequently seek out medical attention, with most patients returning during the first post-operative week for evaluation of bleeding, pain, and dehydration. This young female child presented for routine adenotonsillectomy. She had recent respiratory infection the week prior to surgery. She did well during surgery but was tachycardic throughout and into the post-operative period. She was admitted for monitoring and observation, hydration, and pain management. While it was reasonable to monitor for post-operative complications, she was overall hemodynamically stable. She initially required supplemental oxygen for periodic desaturations, pain was well controlled with Tylenol, and her oral intake improved slowly over the course of her hospital stay. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oligodontia in the maxilla and mandible

Treatment: partial upper denture and partial lower denture

The insurer denied coverage for partial upper denture and partial lower denture

The denial is upheld overturned


Based on review of the submitted documentation which includes copies of panoramic radiographs and insurer correspondence, it appears that this patient presented for evaluation and comprehensive dental care. Recommended treatment was for maxillary and mandibular removable partial dentures to restore function. The insurer has denied these services stating that the clinical circumstance does not meet clinical criteria for approval. Therefore, the services are deemed not medically necessary. The patient's daughter is appealing on behalf of the patient.

Upon review of the documentation, in particular the radiographs the patient exhibits oligodontia in the maxilla and mandible. Review of the remaining dentition on radiograph indicates a level of moderate periodontal alveolar bone loss corresponding to periodontal disease. However, the teeth that would be supports for the removable partial dentures are stable and would be adequate abutment teeth. This treatment of a removable partial dentures is a standard of care in dental practice for this clinical circumstance. As this is a covered service and indicated for restoration of function and occlusal stability, the partial dentures are considered medically/dentally necessary, and meets the insurers criteria for approval.

Partial upper denture and partial lower denture is considered medically necessary for this patient.

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 partial upper denture and partial lower denture services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postoperative fluid overload
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult male for which an inpatient admission is under review. He had coronary bypass surgery 10 days prior and presented with lower extremity edema and intermittent chest pain. There was also shortness of breath.

The patient's BP (blood pressure) was mildly elevated, other vital signs were normal. The oxygen saturation was 100% on room air. Electrolytes were normal. The BNP (brain natriuretic peptide) was 1110. The patient's ECG (electrocardiogram) was reported as non-acute. A CT (computed tomography) angiogram is negative for pulmonary embolism. A chest x-ray demonstrated a left pleural effusion. He was administered some intravenous Lasix. The chest pain was thought to be incisional.

By the day after admission, he was reported as feeling better with improved edema. He was having no shortness of breath and still some incisional pain. His oxygen saturation was 95%. Echocardiography demonstrated normal LV (left ventricle) function. There was a small pericardial effusion. He remained stable and was discharged.

This patient presented with some postoperative fluid overload, which improved with medical therapy, including diuretics, and remained stable. He was an early responder to medical therapy. There was no hemodynamic instability, worsening cardiac symptoms, severe electrolyte abnormality, renal failure, need for ongoing oxygen support, severe arrhythmia, acute coronary syndrome, myocardial infarction, need for ongoing in-hospital intravenous medications, need for mechanical or pharmacologic cardiac support, or administration of high risk medications requiring in-hospital monitoring.

In the setting of this case, an inpatient level hospitalization, compared to for example observation, has not been established standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID positive
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This elderly female patient presented complaining of four days of weakness, diaphoresis, Ioss of appetite, cough, dizziness, and lethargy. Her vital signs were stable. Her blood pressure was 97/65. The patient's pertinent labs included COVID positive, blood urea nitrogen (BUN) / creatinine (Cr) was 33 / 1.79, and lactate was 5.7. Treatment in the emergency department included intravenous fluids. The records show the patient was admitted. The plan of care included intravenous fluids. On day #2, renal function had improved. The patient was cleared for discharge.

The proposed treatment was not medically necessary. 

This patient was admitted with a viral illness. The patient was hemodynamically stable. The information does not support fever or pneumonia. The patient's labs were consistent with mild dehydration, which responded to intravenous fluids. The patient did not have severe electrolyte abnormalities. The patient had not failed an observation level of care. The intervention provided with intravenous fluids did not require an acute inpatient level of care. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

central nervous system
home health care

Diagnosis: weakness/cerebrovascular accident (CVA) 
treatment: home health care
The insurer denied Additional Personal Care Services Level 2 (beyond 56 hours per week). The health plan's determination is overturned.

The patient is a female with past medical history of cerebrovascular accident (CVA) and resultant right-sided weakness, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), morbid obesity, bipolar disorder, schizophrenia, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, opioid dependence with methadone treatment, anemia, and urinary incontinence who had a universal assessment performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, bathing, and dressing lower body while extensive assistance with tasks of managing finances, managing medication, phone use, transportation, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at limited assistance with tasks of bed mobility and eating.

Additional Personal Care Services Level 2 (beyond 56 hours per week) are medically necessary for this patient.
There is documentation from the patient's medical providers of medical necessity of increased PCA (personal care assistant) services. The patient has assistance needs with all activities of daily living (ADL) / Instrumental activities of daily living (IADL). Specifically, the patient requires extensive assistance with walking, locomotion, and transfer toilet while maximum assistance with task of toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The plan incorrectly assumed the patient has informal help outside of the currently assigned PCA service hours. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services Level 2 (beyond 56 hours per 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: Upheld

Diagnosis:  End stage renal disease, left arteriovenous fistula.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient was admitted for malfunctioning dialysis access. He was evaluated by nephrology and vascular surgery and underwent arteriovenous fistula (AVF) repair without complication and was discharged.

The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolyte disturbance. He did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain, and he was able to tolerate oral diet and did not require total parenteral nutrition. He tolerated the procedure well and was discharged in 48 hours.

When taking into account the member's exam, imaging, and lab findings as well as his lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, he had no requirements for inpatient level of care.

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.