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

Diagnosis:  Plantar Fasciitis.
Treatment:  Orthotic Shoes.

The insurer denied coverage for orthotic shoes.  The denial is overturned.

The patient has been seen for pain to the left heel and the bilateral lower extremities.  The patient has been using orthotics, which they have outgrown, and supportive shoes and has taken non-steroidal anti-inflammatory drugs (NSAIDs) with no relief.  On initial exam the patient has pain to the left heel worse than the right, and this extends from the medial to the lateral aspect of the arch.  The patient is unable to do heel raise. Furthermore, the patient has ligamentous laxity and excessive pronation. The patient was diagnosed with flat foot deformity, valgus deformity and plantar fasciitis. Per the records the patient was given heel cups and was told not to ambulate barefoot.  On the patients subsequent exam, there was continued pain to the medial arch, now diagnosed to posterior tibial tendinitis, and the patient was wearing an old pair of custom orthotics that they had outgrown. It was recommended that the patient get a new pair of custom orthotics as a result.  The patient's insurance company has denied the orthotics.

In the reviewer's expert opinion, the decision should be overturned, as it is well documented in the literature, that in cases where all conservative measures have been attempted custom orthotics play a major role prior to and after surgical intervention.  "Children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility" (1).  Furthermore, a systematic review found that orthotics "show potential as a treatment method for children with flexible pes planus" (2).  As such, it is in the best interest of this young patient to use custom orthotics prior to having to undergo any type of surgical intervention for his ongoing pain and discomfort.

Based on the above, the insurer's denial must be reversed. 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 orthotic shoes is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, history of stroke, chronic kidney disease, hypertension, and dementia
Treatment: Consumer Directed Personal Assistance Services 8 hours per Day, 7 Days Per Week (Monday through Sunday) A Total of 56 Hours per Week
The insurer denied: Consumer Directed Personal Assistance Services 8 hours per Day, 7 Days Per Week (Monday through Sunday) A Total of 56 Hours per Week
The denial is overturned.

This patient is an elderly female. Her medical conditions include heart failure, history of stroke, chronic kidney disease, hypertension, and dementia. She has a recent diagnosis of 
pericardial effusion and pleural effusions. She lives with her stepdaughter, who is her Consumer Directed Personal Assistance Services (CDPAS) personal assistant and assists past CDPAS (Consumer Directed Personal Assistance Services) hours. Denial of consumer directed personal assistance services for a total of 56 hours per week is being appealed. The health plan approved 43 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, transportation, bathing, dressing, and toileting; extensive assistance with personal hygiene; and limited assistance with walking, locomotion, bed mobility, and eating. She has frequent bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, toilet use, bed mobility, and eating.

The Consumer Directed Personal Assistance Services 8 hours per Day, 7 Days Per Week (Monday through Sunday) A Total of 56 Hours per Week are medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. The patient receives consumer directed personal assistance services for a total of 43 hours per week. Denial of increase to 56 hours per week is being appealed. This patient has multiple chronic conditions, including recent diagnosis of pericardial effusion and pleural effusions. Uniform Assessment System (UAS) evaluation completed 3 months ago shows she needs assistance with all activities of daily living. She has frequent bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, toilet use, bed mobility, and eating. The information provided shows that this patient has significant limitations in functioning. Her medical conditions have progressed, and there has been a significant decline in her level of functioning between Uniform Assessment System evaluations. The patient's impairment and level of assistance needed with activities of daily living support an increase in CDPAS (consumer directed personal assistance services) to a total of 56 hours per week.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low Back Pain.
Treatment:  The Intracept System (code: 64628 x 1 unit).

The insurer denied: The Intracept System (code: 64628 x 1 unit).  The denial is overturned.

The patient is an adult female with a history of lower back pain that has been ongoing for two years. She has experienced short-term benefit from epidurals. She has more pain standing from sitting and prolonged standing, along with forward bending. She had magnetic resonance imaging (MRI) 4 months ago with severe central canal stenosis at L (lumbar) 4-5 along with multilevel facet arthropathy, with Modic Type 1 change at L5 and S (sacral) 1 vertebral bodies. Past interventional treatments have been bilateral L5-S1 transforaminal epidural steroid injections, which have provided short-term benefit. The health plan's reason for denial was that the provider had not submitted documentation that demonstrates improved outcomes in the literature or by societal guidelines. Therefore, the Intracept procedure (thermal destruction of the basivertebral nerve) is considered investigational. The treating provider's reason for appeal is to perform the Intracept procedure.

The health plan should cover the Intracept procedure.

The Intracept or thermal radiofrequency of the basivertebral nerve has multiple articles providing convincing evidence for success with this procedure for Modic changes. Therefore, the health plan should cover the Intracept procedure. The requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease. Specifically, for vertebrogenic pain, there is no standard treatment. The patient has a multifactorial presentation with Modic changes, facet arthropathy, and central canal stenosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low Back Pain.
Treatment:  The Intracept System (code: 64628 x 1 unit).

The insurer denied: The Intracept System (code: 64628 x 1 unit).  The denial is upheld.

The patient is an adult female. According to the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes on magnetic resonance imaging (MRI). The patient had pain and failed treatment for greater than six months. Prior treatments include activity modification, medication management, physical therapy, and transforaminal epidural steroid injection. Four months ago, the patient presented with back pain that is constant, aching, and aggravated with standing and lumbar flexion. The patient has tried formal physical therapy.

The health plan should not cover the Intracept procedure.

Based on the documentation provided, the requested Intracept procedure is not recommended at this time. Although the patient has a history of chronic low back pain, there was lack of documentation of any confirmatory findings on exam. Exam noted negative findings along the lumbar spine. Additionally, the magnetic resonance imaging report did not demonstrate any degenerative endplate changes. As such, the proposed treatment is not recommended in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low Back Pain.
Treatment:  The Intracept System (code: 64628 x 1 unit).

The insurer denied: The Intracept System (code: 64628 x 1 unit).  The denial is upheld.

The patient is an adult female with midline and low back pain that began 2 years ago. Her past treatments include physical therapy, transforaminal epidural steroid injections, Tylenol, baclofen, diclofenac gel, gabapentin, and tramadol. The patient's pain level is a 3/10 as of 4 months ago. Magnetic resonance imaging (MRI) of the lumbar spine shows L (lumbar) 3-4 right-sided disc protrusion with foraminal stenosis, L4-5 marked central canal stenosis with grade 1 spondylolisthesis and moderate neuroforaminal stenosis, and L5-S (sacral) 1 marked narrowing to the thecal sac due to epidural lipomatosis with moderate right and marked left neuroforaminal stenosis. The request for Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested Intracept procedure.

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. At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit without a disproportionately greater risk of harm or complications than other possible treatments and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such, the health plan should not cover the Intracept procedure. The requested health service or treatment has not been proven to be more beneficial than any standard treatment for the patient's condition or disease. Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e., non-steroidal anti-inflammatory drugs [NSAIDs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor treatments), and interventions (i.e., epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cervical spondylosis 
Treatment: home health care
The insurer denied Consumer Directed Personal Assistance: Total of 24 Hours per Week. The health plan's determination is overturned. 

This is a case review for a male with medical history notable for recent surgery for disc herniation, cervical spondylosis with myelopathy, and rheumatoid arthritis. The patient and his care team requested Consumer Directed Personal Assistance: Total of 24 Hours per Week.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has difficulty performing personal tasks since his recent surgery for disc herniation. The physician requests assistance with opening pill bottles due to weakness with his hands as one example of his personal care needs.

The requested Consumer Directed Personal Assistance: Total of 24 Hours per Week is medically necessary for this patient.
The patient has several functional limitations which inhibit his ability to complete Instrumental activities of daily living (IADL). He also requires assistance with bathing and dressing. The task tool recommended 4-5 hours per day to address these needs, which is a reasonable estimation of the amount of help he would need per day. The requested increase is therefore medically necessary and reasonable for a patient with his degree of functional limitation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: urinary tract infection
Treatment: inpatient stay

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female with a history of diabetes mellitus (DM), hypertension (HTN), and recurrent urinary tract infection (UTI) who presented with fevers, dysuria, urinary frequency and flank pain for two days duration. She denied cough, chest pain, shortness of breath, headache, neck stiffness of ear pain. Her vitals showed that she was afebrile with a pulse of 127, a blood pressure of 181/105, a respiratory rate of 16, and a room air pulse oximetry of 99%. On exam, she was not in any acute distress and she had left sided costovertebral angle tenderness. 

The inpatient admission was medically necessary based on the documentation provided. The patient presented with suspected pyelonephritis in the setting known severe left hydronephrosis/hydroureter. A complicated urinary tract infection in the setting of significant uropathy is an indication for an inpatient admission based on Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 26th urinary tract infection guidelines. In addition, she also had hyperglycemia and evidence of poorly controlled diabetes which placed her at further increased risk of complication and a poor outcome without appropriate management. Admission to an inpatient setting with close monitoring, IV antibiotics and urologic consultation was appropriate and necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Pain
Treatment: Pain management (additional pain injections - 62321 x1)
The insurer denied: Pain management (additional pain injections - 62321 x1)
The denial is overturned.

The patient is an adult female who presented due to an acute exacerbation of chronic neck and right upper extremity pain. The pain was rated a 10 out of 10. Past treatments include non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and home exercise for more than four weeks. The pain is affecting her ability to perform activities of daily living (ADLs). Examination shows right trapezius tenderness and increased pain with right lateral rotation as well as 4/5 bilateral upper extremity strength. The patient was previously seen in 2 years ago and 3 years ago chronic neck pain. Magnetic resonance imaging (MRI) of the cervical spine from shows multilevel disc degeneration/osteophyte bulge/protrusion most significant at C (cervical) 4-7. Physical therapy notes from last year were provided. The request for cervical interlaminar epidural steroid injection was denied as not medically necessary based on the information provided that it did not meet the criteria because the patient has already been treated for 12 months or more than four injections within 12 months.

The requested health service is medically necessary.

The patient is presenting with acute on chronic neck and upper extremity pain. The pain was rated a 10 out of 10. Past treatments include non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and home exercise for more than four weeks. The acute nature of the current exacerbation is interfering with activities of daily living and has not responded to non-steroidal anti-inflammatory drugs or physical therapy treatment. As such, the requested service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoporosis with compression fracture of the lumbar vertebrae
Treatment: Home health care
The insurer denied Personal Care Assistance Services: 84 Hours per Week 
The health plan's determination is upheld.

This is a case review for a female with medical history notable for osteoporosis with compression fracture of the lumbar vertebrae, walking difficulty, and mixed incontinence. The patient and her care team requested Personal Care Assistance Services: 84 Hours per Week.

The requested Personal Care Assistance Services: 84 Hours per Week is not medically necessary for this patient.
The patient has shown a decline in functional status as a result of her recent compression fracture. Based on the documentation provided, it is unclear which functional deficits are acute secondary to her fracture and which are chronic in nature. She continues to undergo physical therapy, and there were no notes from the nursing home indicating whether or not her improvement has plateaued. There were no letters of medical necessity or treatment plan notes from the nursing facility. The health plan approved an increase from the recommended 44 hours per week based on the task tool up to 56 hours per week. It is unclear what the patient's final level of functional need will be, and if the increase that was already given to the patient will or will not be sufficient to meet her personal care needs. Therefore, the requested increase to 84 hours per week is not demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Stenosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient presented to the hospital for a scheduled lumbar laminectomy lumbar (L)4-5, L5-sacral (S)1 and lumbar microdiscectomy L4-5, L5-S1 with endotracheal anesthesia. After surgery, the patient was transferred to the post anesthesia care unit (PACU). The patient was placed on telemetry. The patient was given intravenous (IV) fluids and IV pain medications. During the admission the patient was seen by physical therapy (PT). Per the appealer, the inpatient admission was warranted for this patient who was a medically complex and psychologically fragile young person.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The surgery was complex and prolonged, necessitating the need for the inpatient admission. There were post-operative complications, in that there was difficulty with ambulation, a percutaneous drain, and some postoperative numbness and weakness, as well as chest tightness; all of which are barriers to discharge.      

This patient who underwent laminectomy and microdiscectomy. As previously stated, The surgery was complex and prolonged, necessitating the need for the inpatient admission. There were post-operative complications, in that there was difficulty with ambulation, a percutaneous drain, and some postoperative numbness and weakness, as well as chest tightness; all of which are barriers to discharge.

As such, the inpatient admission is considered medically necessary for this patient.

"Laminectomy is one of the most common procedures to decompress the spinal canal in cases of narrowing secondary to various conditions such as degenerative stenosis, fracture, primary and secondary spinal tumors, abscess, and deformity. The spinous process and the lamina are removed limited laterally to the medial part of facet joints. The central canal, the lateral recesses, and the neural foramina must be decompressed for good clinical recovery and the prevention of failed back surgery syndrome" (Estefan, M., et al. 2023).

"Lumbar disc herniations (LDH) are a relatively common and early manifestation of degeneration of the lumbar spine. The reported incidence of LDH is 2%~3% and the prevalence is around 12%. Prevalence of 4.8% among men and 2.5% among women above 35 years of age. The most common site of LDH is at L4-L5 and/or L5-S1. Surgery for LDH accounts for the most common indication for performing spinal surgery. Microdiscectomy, with its smaller incision, less traumatic approach, and better visualization of the operative field than standard open discectomy, is considered the gold standard for removing most lumbar disc herniations" (Dowling, T. J., et al. 2023).

Based on the above, the insurer's denial must be reversed. 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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Skin
Ambulance

Diagnosis: burn
Treatment: air ambulance
The insurer denied the air ambulance.
The health plan's determination is upheld. 

The patient is a young male without significant past medical history who presented to the Emergency Department with his mother with concerns for a burn. The Mother reported that the patient pulled a pot of boiling water onto himself. He was evaluated and treated by the ED physician. The child reportedly got on a chair and pulled the pot toward himself with resultant burns to his right neck, chest, and right upper extremity. No other injuries were noted. His immunizations were reported to be up to date. The burns were noted to be 14% of total body surface area. Attempts at intravenous (IV) placement were unsuccessful. He was provided with oral ibuprofen for pain control and his burns were dressed with bacitracin. The case was discussed with the burn team at a burn facility and the patient was accepted to their facility for further management of partial thickness burns to his chest, abdomen, and right upper extremity. He was transported via air ambulance to the other facility where he remained for nine days and underwent surgical debridement and dressing changes.

The requested air ambulance transport 44 miles was not medically necessary to get the patient to a qualified pediatric burn center.
The use of air ambulance services is considered medically necessary when a life-threatening condition, such as a major burn requiring treatment in a Burn Center is present, and the following 3 criteria are met: the ambulance has the necessary equipment to address the needs of the patient, transport by means other than ambulance are contraindicated, and the time needed to transport by land poses a threat to the patient or would be 30 minutes or longer than air transport. Additionally, mileage associated with air ambulance service is "medically necessary up to the distance required for transport to the nearest appropriate facility," which in this case is only 43 miles away. The patient was transported to a facility, which is 87 miles away. There is no evidence that the staff attempted to transfer to the closer facility or that there were extenuating circumstances that would justify transferring to the more distant facility.