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

Diagnosis: Decreased mobility
Treatment: CDPAP (Consumer Directed Personal Assistance Program) 
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 17.5 Hours per Day, 7 Days per Week [Total of 122.5 Hours per Week]. The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, hyperlipidemia, chronic venous insufficiency, recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) on chronic anticoagulation, major depressive disorder, osteoarthritis, hypothyroidism, incontinence of bowel and bladder, obesity, and chronic obstructive pulmonary disease (COPD) who had been hospitalized with subsequent Skilled Nursing Facility (SNF) stay with request for CDPAP (Consumer Directed Personal Assistance Program) services. The patient was hospitalized with DVT and PE following a fall, was started on anticoagulation, subsequently had left lower quadrant hemoperitoneum and uncontrolled epistasis. During her stay at SNF the patient had urinary tract infection (UTI) x (times) 3.

CDPAP Services: 17.5 Hours per Day, 7 Days per Week [Total of 122.5 Hours per Week] are medically necessary for this patient.

The patient's primary care physician documents worsening functional status with need for 24-hour aide services. There is documentation of multiple falls over the last year requiring hospitalization and emergency room visits. The patient is on chronic anticoagulation for treatment of DVT/PE and is a higher risk for morbidity and mortality if she were to fall. The patient requires maximum assistance with walking and total assistance with locomotion. The patient requires maximum assistance with transfer toilet and toilet use. 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 insurer assumed the patient has informal help outside of the hours of CDPAP services. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient needs frequent changing of incontinence products to avoid skin breakdown. 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, CDPAP Services: 17.5 Hours per Day, 7 Days per Week [Total of 122.5 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: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intracept Procedure. 

The insurer denied the Intracept procedure. The health plan's determination is upheld. 

This is a male who has persistent back pain with radiation to the hips, thighs and to the knees. His back pain is achy with pain and numbness in the legs. Pain level is 7 to 9/10. He had tried acupuncture, chiropractic treatment and physical therapy (PT) without success. Physical exam (PE) was unremarkable except positive facet loading tests. Lumbar magnetic resonance imaging (MRI) revealed severe spinal stenosis from L1 to S1, Disc herniation at L3-4 and L5-S1 impinging right L4 and left S1 nerve roots. This patient was recommended to have the Intracept procedure for persistent pain. 

The proposed Intracept Spinal procedure is not likely to be beneficial for the insured's medical condition. 

The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. The MRI revealed severe spinal stenosis from L1 to S1, and disc herniations at L3-4 and L5-S1 impinging right L4 and left S1 nerve roots. Physical exam (PE) was remarkable for facet load test, which suggested facet arthritis might contribute to his symptomology. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with radiographic evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. 
Given this patient's medical history of severe spinal stenosis and disc bulge with nerve impingement, positive facet loading on PE, and the current clinical studies on Intracept procedure, he is not an appropriate candidate for this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intracept Procedure. 

The insurer denied the Intracept procedure. The health plan's determination is upheld.

The patient is a male with history chronic low back pain of undisclosed duration. There is reported axial low back pain with radiation into upper aspect of both lower extremities in addition to "leg numbness and pain". Symptoms are aggravated by all activity and with no alleviating factors. Symptoms are unresponsive to acupuncture, physical therapy, chiropractic care, nonsteroidal anti-inflammatory drug (NSAID) and muscle relaxants. The patient is currently prescribed opioids chronically. 
On physical exam, there is bilateral lumbar paraspinal tenderness but otherwise examination is unremarkable except for obesity (body mass index (BMI) > 32)
A Lumbosacral magnetic resonance imaging (MRI) report describes multilevel severe spinal stenosis of degenerative type superimposed upon congenital stenosis with some component of epidural lipomatosis. In addition, there are "degenerative end plate changes at L4-5 with superimposed mild acute reactive bone edema". 

The Intracept Surgical Spine Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
In the setting of severe multilevel lumbar spinal stenosis with low back pain and significant lower extremity pain aggravated by ambulation, a diagnosis of neurogenic claudication is likely. In fact, such a diagnosis with such symptoms was an exclusion criterion in the studies regarding the Intracept procedure. This is explicitly stated in the provider's note. In such a case, epidural steroid injection or other treatment of symptomatic lumbar spinal stenosis would be the standard of care. Furthermore, the planned diagnostic medial branch blocks (MBB) are not documented as completed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intracept Procedure. 

The insurer denied the Intracept procedure. The health plan's determination is upheld. 

The patient is a male with chronic pain. Pain is in the lumbar spine with radiation across the low back with radiation to the hips and thighs. Pain is rated 7 out of 10. The patient has had no prior surgery. Magnetic resonance imaging (MRI) lumbar spine demonstrated degenerative disc disease and prominent epidural fat located from L (lumbar)1-S (sacral)1. Disc bulges and height loss contribute to multilevel neural foraminal stenosis. Disc herniations at L3-4 and L4-L5 are noted. Physical exam demonstrated mildly antalgic gait, facet loading test positive to the left and right. Medications have included opioids in the past. Under review is the Intracept Surgical Spine Procedure 

The proposed Intracept Spine Surgery is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
This procedure is not recommended despite promising early reports, and 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 Intracept Spine Surgery is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Prosthetics. 
The insurer denied vacuum pump socket (both prosthetics). 
The denial is overturned.

The patient is a male with medical history significant for bilateral below the knee amputations subsequent to a congenital birth defect. The subject under review is whether the proposed health service or treatment of Vacuum pump socket (both prosthetics) is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The proposed volume management moisture evacuation system for both prosthetics is likely to be more beneficial than any standard treatment. 
The patient maintains a very active lifestyle with his job requiring him to be on his feet 6-8 hours per day. In addition, he is an active person who has a daily fitness routine and enjoys playing golf, hiking and travel. Documentation noted that the patient had a significant weight loss (20 pounds) and has since been experiencing continuous loss of suction. Essentially, this means that when he is walking his residual limb is slipping up and down inside the prosthesis (referred to as pistoning). This constant friction is dangerous and can result in skin breakdown and development of wounds. In addition, it places the patient at a high fall risk as his residual limb is sliding up and down in his prosthesis putting him at increased risk of loss of balance and subsequent fall. Furthermore, it places him at risk of musculoskeletal (specifically back) injuries. Possibly even more concerning is that it changes his gait dynamic and as the patient is a bilateral, below the knee, amputee he does not have the luxury of being able to compensate with a "good leg." Also, per the provider, "the patient's weight loss has exceeded the prosthetic material's ability to reduce in circumference, length, or classification level." Therefore, it is not possible for this patient's problem to be resolved by adjustments. Also, as noted above, the patient is highly active and has a physical job which further supports the proposed volume management moisture evacuation system for both prosthetics as it will provide the patient with secure suspension regardless of volume status (weight changes will not affect his ability to function safely in his field of work).
Therefore, it is appropriate, and considered standard of care in Physiatry for an individual such as this active, bilateral lower extremity amputee who has developed loss of suction with subsequent pistoning to be prescribed and obtain the proposed volume management moisture evacuation system for both prosthetics.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Prosthetics. 
The insurer denied vacuum pump socket (both prosthetics). 
The denial is upheld.

The patient is a male with a history of congenital transtibial amputation at the level between the knees and ankles of both legs. At issue is whether the bilateral sockets addition to lower limb prostheses, vacuum pump, residual limb volume management and moisture evacuation system with modifier LT (left side) and modifier RT (right side) are likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The proposed health service or treatment Vacuum pump socket (both prosthetics) is unlikely to be more beneficial than any standard treatment or treatments for the patient's conditions. The requested bilateral sockets are in addition to lower limb prostheses, vacuum pump, residual limb volume management and moisture evacuation system with modifier LT (left side) and modifier RT (right side). The patient has a history of congenital transtibial amputation at the level between the knees and ankles of both legs.

The Vacuum pump socket (both prosthetics) is not considered standard of care and there are no well-designed well conducted studies published in peer-reviewed journals to support this device, demonstrate that this device affects health outcomes, or show that this device is equally or more effective than conventional therapies. There are many standard treatments for the diagnosis of congenital transtibial amputation at the level between knee and ankle of both legs including standard pin suspension sockets (both prosthetics). The use of the Vacuum pump socket (both prosthetics) is not supported by the peer-reviewed medical literature is not considered the standard of care in United States this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Prosthetics. 
The insurer denied vacuum pump socket (both prosthetics). 
The denial is overturned.

The patient is a male with bilateral congenital limb deficiencies which resulted in bilateral transtibial amputations. He is very active and employed but his current prostheses cannot maintain suction and have become unstable. He was denied a vacuum pump suspension system by his health plan. The subject under review is whether the requested vacuum pump socket is likely to be more beneficial than any standard treatment for this patient.

The proposed vacuum pump socket is likely to be more beneficial than a standard socket and thus is medically appropriate. The vacuum generated between the residual stump and prosthesis allows for a better fit and improved suspension with less pistoning. There is reduced volume fluctuation and improved blood flow to the residual stump. As a result of the stability offered by the vacuum, the patient's gait is improved with greater efficiency. This patient is a bilateral transtibial amputee and after a 20-pound weight loss he has experienced instability with his prostheses. He lives a very active lifestyle and is employed in a position that requires prolonged standing; thus, stability is imperative. His current prostheses can no longer provide the proper suspension and support he requires. This device will improve the fit, comfort, stability, and safety of the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Ulcerative Colitis
Treatment: Pharmacy/Prescription Drugs-Asacol HD
The health plan denied the exception request for Asacol HD as it did not meet plan criteria. 
The reviewer has overturned in whole the health plan's determination.

The patient has Ulcerative Colitis. Per the patient letter he was on Asacol HD with few flares; on generic mesalamine, he has had upset stomach, bloating, gas, eructation, diarrhea, and urinary symptoms (incomplete evacuation and persistent urge to urinate); he has failed Apriso and Lialda. Per the provider letter he failed Apriso (with intermittent nausea, bloating, and Ulcerative Colitis flare) and Lialda (with similar adverse symptoms); on generic mesalamine, he has had significantly more discomfort than he had on Asacol HD; he has a sulfa allergy. Per the provider letter, on generic mesalamine he has had more colonic mucosal inflammation, constipation, change in bowel habits, cramps, bloating, flatulence, urologic discomfort, and pelvic floor dysfunction. The coverage is requested for Asacol HD (mesalamine delayed release tablets) for the treatment of Ulcerative Colitis.

The request for Asacol HD is supported. Mesalamine has proven effective for the treatment of Ulcerative Colitis in randomized, double-blind, multicenter trials, although various formulations result in release at distinct times and locations in the gastrointestinal tract, making them clinically different from each other [1-4]. Specifically, Asacol HD is different from alternatives such as Lialda, Apriso, Salofalk, Mezavant extended release (XL), Pentasa, balsalazide, and sulfasalazine, and their respective generic formulations, each with release in different portions of the gastrointestinal tract and at different potential hydrogen (pH) levels [1-7]. The result of changing therapy can be inadequate control by a different formulation which directs the drug to a different part of the gastrointestinal tract. Sulfasalazine is inferior to mesalamine and associated with a higher rate of intolerance in some studies [5]. Additionally, Ulcerative Colitis flares can be induced by salicylate medications, and changing therapy can expose the patient to this risk [8]. In this case, the patient has had uncontrolled disease or adverse symptoms with multiple 5-aminosalicylate formulations and with generic mesalamine, and better disease control and fewer adverse symptoms on Asacol HD. An exception is supported in this case to use Asacol HD as the patient is otherwise at risk for disease destabilization, with complications such as disease flare, toxic megacolon, or need for hospitalization or surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Braces. 

The insurer denied the Braces. 
The determination is overturned. 

The patient has a Class II Subdivision left malocclusion with crowding and a retrognathic mandible. Per the narrative provided by her orthodontist, she has an 8-millimeter (mm) overjet. She is treatment planned for orthodontics. At issue is whether braces are medically necessary. 

There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Orthodontics will make these teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (2) 
For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis, chronic obstructive pulmonary disease, carpal tunnel syndrome (CTS), alcoholic cirrhosis and lymphedema.
Treatment: Increase Home Care/Personal Care HHC-Level 2 Personal Care Services Per 15 Minutes to 30 Hour(s) Per Week.
The insurer denied the Increase Home Care/Personal Care HHC-Level 2 Personal Care Services Per 15 Minutes to 30 Hour(s) Per Week.
The denial is upheld.

The patient is a male. His conditions include osteoarthritis, chronic obstructive pulmonary disease, carpal tunnel syndrome (CTS), alcoholic cirrhosis and lymphedema. Denial of increase personal care services (PCS) to 30 hours per week is being appealed. The plan approved an increase in PCS (personal care service) to 21 hours per week.

The patient states that due to his recent diagnosis of lymphedema, it is difficulty to complete tasks due to leg swelling. Uniform Assessment System (UAS) evaluation completed shows independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; limited assistance with managing finances, bathing, and lower body dressing; supervision with managing medications; independent with phone use, personal hygiene, upper body dressing, walking locomotion, toileting, bed mobility, and eating. He uses a cane for support. He has occasional bladder incontinence. UAS (Uniform Assessment System) evaluation completed most recently shows no significant change in functioning.

An appeal statement notes the patient has chronic conditions including a brace for CTS (carpal tunnel syndrome) that makes him unable to perform household duties and personal care needs.

No, the increase in personal care services to 30 hours/week is not medically necessary.
This patient has multiple chronic medical conditions, including newly diagnosed lymphedema. Denial of increase personal care services (PCS) to 30 hours per week is being appealed. The plan approved an increase PCS (personal care service) to 21 hours per week.

The UAS (Uniform Assessment System) evaluations performed shows the patient requires assistance with meal preparation, housework, shopping, managing finances, bathing, and lower body dressing. There has been no significant decline in functioning between evaluations. He has occasional bladder incontinence. Appeal statements note the patient needs assistance with ADLs (activities of daily living) due to limitations as a result of lymphedema and CTS (carpal tunnel syndrome). The approved PCS (personal care service) 21 hours per week is appropriate to meets the patient's needs for assistance with ADLs (activities of daily living) and personal care. PCS (personal care service) is not indicated when no tasks are being performed. The proposed increase in PCS (personal care service) to total 30 per week is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.