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

Diagnosis: Dementia, schizoaffective disorder.
Treatment: Social Day Care (SDC) For A Total of 4 Days Per Week.
The insurer denied: Social Day Care (SDC) For A Total of 4 Days Per Week.
The denial is overturned.

This patient is an elderly female with dementia, schizoaffective disorder, and bipolar disorder. The denial of social daycare (SDC) for a total of four days per week is being appealed. The health plan approved consumer personal care aide (PCA) four hours per day, five days per week, and five hours per day, two days per week, for a total of 30 hours per week. An appeal statement from New York State's ombuds program for managed care notes that the patient's mood and behaviors have improved when she participates in a day program. The patient attends daycare for seniors who have dementia. The program provides assistance with activities of daily living (ADLs) as well as social activities. A letter from the director of the social adult day program, notes the patient would benefit due to her diagnosis. Social activities and exercise will provide routines and movement. A letter from the nurse practitioner notes an increase in the patient's day program will improve her overall quality of life. The patient's behavior, mood, and supervision improve with participation in a day program.

The proposed treatment is medically necessary. 

Adult daycare centers may focus primarily on social interaction, provide medical care, or be dedicated to Alzheimer's care. Adult daycare can provide a break for the caregiver and social interaction. They provide a variety of services and activities, including social activities. This patient receives a personal care aide (PCA), but this does not provide socialization and support with dementia care that would be provided in a social daycare program. The appeal statements report the patient's mood and behavior have improved while participating in social daycare. The requested social daycare for a total of four days per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthritis, spinal stenosis, carpal tunnel syndrome, and bipolar disorder.
Treatment: Personal Care Assistance Services.
The insurer denied: Personal Care Assistance Services.
The denial is upheld.

This patient is an adult female with arthritis, spinal stenosis, carpal tunnel syndrome, and bipolar disorder. Denial of personal care assistance services is being appealed. Uniform Assessment System evaluation performed 9 months ago shows minimally impaired cognition and functional status: maximal assistance with housework; extensive assistance with meal preparation; supervision with phone use; and independence with phone use, bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating. She has urinary incontinence.
A letter from a Provider notes the patient has chronic neck, back, 
shoulder, and knee pain. She has hand numbness due to carpal tunnel syndrome. She needs assistance with activities of daily living (ADLs). A letter from the patient's physician notes the patient has bipolar disorder that manifests with emotional dysregulation, which impairs her ability to perform simple housework and personal hygiene tasks.

The proposed treatment is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals including assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has arthritis and carpal tunnel syndrome. The denial of personal care assistance services is being appealed. Uniform Assessment System (UAS) evaluation completed 9 months ago shows the patient is independent with all activities of daily living, except housework and meal preparation. Appeal letters note the patient requires assistance with activities of daily living due to emotional dysregulation and joint pain. The information provided does not support the requested personal care assistance services. Personal care assistance services are not indicated for supervision, companionship, or when no tasks are being performed. The proposed personal care assistance services are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite/Underbite.
Treatment: Braces.
The health plan denied: Braces.
The determination is: Overturned.

The patient is a female with a Class II malocclusion and anterior crossbite of teeth #6 and #10. There is 1 millimeter (mm) of overjet and 1mm overbite. There is some recession present on tooth #22. She is treatment planned for 30-36 months of orthodontics to correct her malocclusion.
At issue is the medical necessity of braces.
The health plan's determination of medical necessity is overturned in a whole.
The requested health service/treatment of braces is medically necessary for this patient. This patient presents with an anterior crossbite, significant crowding, and a skeletal jaw imbalance. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1,2,3] These problems are much more time-consuming and costly to correct than the patient's current orthodontic problem.
The patient has significant maxillary anterior crowding with #6 and #10 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time,[4] which will make treating this occlusion at a later time more difficult. Tooth #22 already has some recession, and further labial movement of #22 will likely lead to the need for future periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia, depression, ADHD (attention deficit hyperactivity disorder)
Treatment: Personal Care Aide for 48 Hours per Week
The insurer denied: Personal Care Aide for 48 Hours per Week
The denial is upheld.

This adult male patient has medical conditions that include schizophrenia, depression, and attention deficit hyperactivity disorder (ADHD). The denial of personal care aide for 48 hours per week is being appealed. The health plan approved 28 hours per week. The patient's Uniform Assessment System evaluation completed three months ago shows moderately impaired cognition and functional status: total dependence with meal preparation and housework; extensive assistance with managing medications, phone use, and transportation; limited assistance with bathing, dressing, and locomotion; supervision with personal hygiene and walking, and independent with toileting, bed mobility, and eating. The patient is continent of bowel and bladder. A letter from the patient's mother notes the patient cannot be left alone. He needs assistance with activities of daily living (ADLs). He tries to leave the house and wander. He is incapable of making decisions on his own. A letter from the patient's physician notes that the patient is a security risk when left alone.

The proposed treatment is not 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. Denial of personal care aide for 48 hours per week is being appealed. The health plan approved 28 hours per week. Uniform Assessment System evaluation completed three months ago shows the patient requires assistance with meal preparation, housework, managing medications, phone use, transportation, bathing, dressing, and locomotion. Appeals statements note the patient is unsafe alone and needs supervision due to being a security risk. Personal care services are not indicated for safety supervision, companionship, or when no tasks are being performed. The needed assistance with activities of daily living (ADLs) can be accomplished with the approved personal care aide of 28 hours per week. The information provided does not support that the patient has functional needs that requires an increase in personal care aide from 28 hours per week to 48 hours per week.
Appeal type: Medical necessity
Decision: Upheld

Central nervous system
Inpatient stay

Diagnosis: Possible seizure
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of recurrent, witnessed seizures. Pertinent history included migraine headaches, but not a seizure disorder. Initial vital signs revealed a temperature of 98.8F, heart rate (HR) 100, blood pressure (BP) 133/83, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 100%. Initial examination documented the patient as alert and oriented with no focal neurologic deficits. 

The inpatient stay was not medically necessary for this patient. The patient had a medical history of migraine headaches who presented with witnessed seizure-like activity. Upon arrival, the patient was alert, oriented, and at baseline neurologic status. Initial laboratory testing was relatively unremarkable and mild, noted abnormalities were not clinically significant. Head imaging with a CT and CT angiogram were unremarkable. The patient was placed in the hospital for observation and additional diagnostic testing. The electroencephalogram (EEG) did reveal rare, localized left temporal sharp waves and oral Keppra was initiated. Following observation care, the patient was at her baseline state of health. There was no recurrence of seizure during the hospital stay. There were no other issues or complications documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Conductive Hearing Loss
Treatment: Balloon dilatation of the eustachian tube surgery
The insurer denied the Balloon dilatation of the eustachian tube surgery.
The health plan's determination is upheld.

The patient is a male with a right sided middle ear effusion. Medical management included nasal steroids. Conductive hearing loss was reported. The computed tomography (CT) scan demonstrated a middle ear effusion. The examination was consistent with a middle ear effusion. There were no previous surgical treatment that had been documented.

The requested health service/treatment of Balloon Dilation of the Eustachian Tubes is not medically necessary for this patient. The standard of care treatment for a chronic middle ear effusion in an adult is a myringotomy or a myringotomy with ear tube placement. Balloon eustachian tube dysfunction studies have not shown over the long term that balloon eustachian tube dilatation is effective in treating a patient with a chronic middle ear effusion.
Balloon eustachian tube dilatation has not been shown to be more efficacious than myringotomy or myringotomy with ear tube placement for the treatment of chronic middle ear effusion.
The majority of studies investigating outcome for balloon eustachian tube dilatation have not been done on patients with chronic middle ear effusion, but rather those with eustachian tube dysfunction and retracted ear drums.

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female. She presented to the emergency ward after two apparent seizures at home. At presentation, the patient was unresponsive. CT (computed tomography) brain was negative. She was treated with Keppra and admitted to the acute inpatient setting for further management. After admission, she had two further spells consistent with seizure, requiring transfer to the intensive care unit. 

The Inpatient Hospital Admission was medically necessary. 

The patient presented with new onset seizure and persistent severe mental status change. An effective seizure treatment could not be established as a lower level of care, as she had seizures after treatment was initiated. The frequency of seizure without returning to baseline between events is consistent with status epilepticus and warrants acute inpatient level of care (Lee, 2020; Shellhaas, 2019).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain Management (Intracept procedure)
The insurer denied: Pain Management (Intracept procedure)
The denial is overturned.

The patient is an adult female. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that has resulted in development of vertebrogenic pain identified by degenerative endplate changes on MRI (magnetic resonance imaging). The patient's pain and failed treatments have lasted more than 6 months. The pain began over a year ago. She has tried medication, PT (physical therapy) and RFA (radiofrequency ablation). The pain is rated 8/10. Per a note dated three months ago, the patient's lumbar spine has severe pain due to flexion, positive for facet loading bilaterally.
An MRI (magnetic resonance imaging) notes acute ongoing reactive marrow changes, with disc edema across both sides L(lumbar) 1-L2 endplates adjacent to a large bridging osteophyte.

The health plan should cover the requested Intracept procedure.

Based on the documentation provided, the requested procedure should be covered. The patient has a history of chronic back pain and despite prior conservative treatments, including physical therapy, injections, as well as medications, the patient continue be symptomatic with positive findings on exam, as well as an MRI (magnetic resonance imaging). The FDA (United States Food and Drug Administration) has approved of the requested procedure for Modic type changes on MRI (magnetic 
resonance imaging). 
The requested Intracept procedure is more beneficial. The patient has tried other standards of treatment and continues to have symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain Management (Intracept procedure)
The insurer denied: Pain Management (Intracept procedure)
The denial is upheld.

The patient is an adult female with low back pain for the past two years. The patient's past treatment history includes physical therapy, radiofrequency ablation, Aleve, Tizanidine, and Tylenol.
As of three months ago, the patient's pain is an 8/10. MRI (magnetic resonance imaging) of the lumbar spine shows moderate to severe multilevel spondylosis with foraminal stenosis, acute ongoing reactive edema at lumbar one to two (L1-2).
The request for Intracept procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the 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 Intracept procedure 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. 
Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e. nonsteroidal anti-inflammatory drugs, 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: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain Management (Intracept procedure)
The insurer denied: Pain Management (Intracept procedure)
The denial is upheld.

The patient is an adult female. She has a chronic history of Iow back pain that began some time ago. The patient has tried medication management, physical therapy and radiofrequency ablations. Magnetic resonance image shows degenerative endplate changes, which can be taken to mean Modic changes. The patient's physical exam does not reveal any neurological injury.

The health plan should not cover the requested Intracept procedure.

The requested Intracept procedure is not likely to be more beneficial than standard treatments. The patient is an adult female. She has a chronic history of Iow back pain that began some time ago. The patient has tried medication management, physical therapy and radiofrequency ablations. Magnetic resonance image shows degenerative endplate changes, which can be taken to mean Modic changes. The patient's physical exam does not reveal any neurological injury.
The Intracept procedure (interosseous basivertebral 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 used 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 a Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized clinical trials (RCT) with five-year results. However, the patient in this case has not failed or attempted all conventional and typical options for common causes of axial low back pain. 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 do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay
Treatment: Root canal tooth 20
The insurer denied root canal tooth 20. The health plan's determination is overturned. 

The patient is a female who presents for the treatment of tooth #(number) 20. Provided for review are a letter of necessity from the provider, a patient narrative, multiple radiographic images, letters of denial, a single American Dental Association (ADA) claim form, and health plan language. 

Due to the extent of decay and the proximity of the decay to the root canal of tooth #20, root canal therapy is required. Teeth with decay and root canal involvement require root canal therapy and the number of teeth in occlusion do not have any influence on the presence of decay nor the need for removal of decay. The tooth is not a single tooth that has no opposing dentition nor is the patient in a terminal dentition state where saving the tooth has no bearing on the chewing function of the patient. Hence, the root canal is medically necessary for tooth #20.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified atherosclerosis
Treatment: Duplex Scan (code: 93880)
The insurer denied Duplex Scan (code: 93880).
The denial is upheld.

The patient is an adult male. He was referred for a carotid Doppler study for risk stratification. The reason for the study was screening for atherosclerosis. His past medical history is unremarkable for prior cerebrovascular accident (CVA), carotid disease, or other neurologic diseases. The request was denied coverage by the health plan as not medically necessary, based on the policy using the Carelon AIM Guideline Vascular Imaging. The denial is being appealed.

The proposed treatment is not medically necessary.

Based on the peer-reviewed medical literature, criteria for performing a carotid Doppler study are not met. These include screening for atherosclerosis in the absence of signs or 
symptoms of disease; extracranial arteriovenous malformation (AVM) or arteriovenous fistula (AVF); extracranial carotid dissection only; in patients who are candidates for carotid revascularization, including five years post-neck irradiation and every three years thereafter; initial evaluation of carotid calcification incidentally detected on nonvascular imaging; diagnosis of suspected carotid stenosis raised by Hollenhorst plaques or retinal neovascularity on retinal examination; management of known carotid stenosis; worsening neurologic symptoms or signs attributable to the anterior circulation; initial baseline evaluation and at six months following carotid revascularization; and surveillance of established carotid disease. Therefore, based on the submitted information and the current published medical literature, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a patient that presented to the hospital complaining of chest pain radiating to the left arm and pedal edema. Past medical history was significant for intravenous (IV) drug abuse, active cocaine abuse and methadone use.  On presentation, the patient's vitals were: pulse 83 and blood pressure 134/69. Physical exam was significant for reproducible chest pain over the left chest wall and bilateral pedal edema. 12 lead electrocardiogram (ECG) revealed normal sinus rhythm without ST or T wave abnormalities. Serum troponin was not elevated at 8.2. The patient was admitted to the hospital for observation and treatment.  Echocardiogram demonstrated a preserved left ventricular ejection fraction and no valvular abnormalities. 

This patient presented with atypical chest pain. The patient's pretest probability of coronary artery disease was low (1).  Utilizing the HEART (History, ECG, Age, Risk Factors, Troponin) score the patient was considered low risk (2).  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST (Sinus tachycardia) changes on ECG was reviewed by Hedayati et al (3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI (Myocardial infarction), and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower 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 inpatient admission is not substantiated.