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

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week 
The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, breast cancer, hypertension, hyperlipidemia, diabetes mellitus type 2, diabetic neuropathy, osteoarthritis, anxiety, depression, coronary artery disease, urinary incontinence, and vitamin B12 deficiency who had been assigned PCA (personal care aide) services assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication and phone use. With tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, and transfer toilet. The patient was assessed at supervision with tasks of bed mobility and eating.

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCA services. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient would need assistance during the hours that her husband is not able to provide informal support hence the request for additional hours. The patient has 24-hour care needs and therefore a time based task total should not of been utilized to calculate hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services 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: Low back pain.
Treatment: Intraosseous basivertebral nerve ablation.
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient with complaints of chronic low back pain. Prior treatment has included lumbar injections, as well as medications. The pain severely impacts activities of daily living (ADLs). The pain can be as high as 9 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine reported Modic type I changes at disc spaces lumbar (L) 5-sacral (S) 1. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intraosseous basivertebral nerve ablation 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: Upheld

Diagnosis: Low back pain.
Treatment: Intraosseous basivertebral nerve ablation.
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient who has bilateral lower back pain. His pain level is 9/10. The patient also has complaints of numbness tingling with muscle spasms and difficulty ambulation. He describes his pain as aching, stabbing, and throbbing. His prior treatments included lumbar transforaminal injections, lumbar medial branch nerve blocks, radiofrequency ablation, and a Medrol Dosepak. The physical examination showed tenderness to palpation in the lumbar paraspinal regions, restricted range of motion of the lumbar spine, and positive facet loading test bilaterally. Magnetic resonance imaging (MRI) showed a disc bulge with posterior annular tear at lumbar (L) 3-4, a small disc osteophyte complex at L5-sacral (S) 1 with disc space narrowing at L5-S1, vertebral body heights are maintained, marrow signal is within normal limits, mild Modic type 1 degenerative signal in the inferior endplate of L5.
At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.

The proposed intraosseous basivertebral nerve ablation is unlikely to be more beneficial than any standard treatment or treatment for the insured's condition.
The Intracept system was designed to treat low back pain from the vertebral body by ablating basivertebral nerves. This patient has persistent back pain with tingling and numbness sensation in the lower extremities. The physical examination documented tenderness to palpation in the lumbar paraspinal region with positive facet loading tests. Magnetic resonance imaging (MRI) showed multilevel degenerative disc disease at L3/4 and L5/S1. Truumees' study supported the efficacy of the Intracept procedure for vertebrogenic pain. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. (1)
Based upon this clinical presentation, the extrusion, and inclusion criteria of the current clinical studies on Intracept procedure, it is unlikely this patient will benefit from Intraosseous basivertebral nerve ablation at L5-S1.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Home health care. 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Live In). 
The health plan's determination is overturned. 

This is a female patient with a history of dementia, a brain tumor, hydrocephalus with atrioventricular (AV) shunt present, hand tremors, osteoarthritis, hypertension, generalized weakness, major depressive disorder, anxiety, and bowel and bladder incontinence. 

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Live In) is medically necessary for this patient.
There is documentation in the Uniform Assessment System (UAS) of the patient requiring maximal assistance with tasks of walking, locomotion, transfer toilet, and 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 these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. The UAS indicates that the patient's level of assistance has increased for most tasks as compared to the previous UAS. There is documentation from the patient's PCP (primary care provider) of deterioration in patient's condition in recent months and medical necessity of increased PCA (personal care assistant) services. Although the patient lives with her spouse and therefore has informal support, the plan cannot assume that the informal support person can provide all needed care outside of the approved PCA hours. 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 activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

Asked to review the case of a patient that presented to the hospital complaining of shortness of breath.  Past medical history was relevant for hypertension, nonischemic systolic congestive heart failure with a left ventricular ejection fraction (LVEF) of 20% and pleural effusions.  On arrival blood pressure (BP) was elevated (172/125) and pulse was regular at 80 beats per minute. Physical exam revealed decreased breath sounds over the right lower lung field.  12 lead electrocardiogram (ECG) revealed sinus rhythm with left ventricular hypertrophy and T wave inversions in the lateral leads. Pro-B type natriuretic peptide (BNP) was elevated (1208).  Chest x-ray revealed cardiomegaly and pulmonary vascular congestion with haziness over the right lung field.  The patient was treated with intravenous diuretic and bilevel positive airway pressure (BIPAP) therapy. The patient was admitted to the hospital for treatment of decompensated heart failure.

No, the health plan did not act reasonably and with sound medical judgment and in the best interest of this patient.  This patient presented with complaints of dyspnea and orthopnea.  Upon presentation, physical exam and laboratory testing confirmed fluid overload due to systolic congestive heart failure. The patient required treatment with intravenous diuretic therapy and was ultimately discharged on oral guideline directed medical therapy.  Failure to admit and treat this patient would have resulted in excess morbidity or even mortality. Patients with chronic congestive heart failure have a high risk of adverse outcomes warranting a higher level of care (Reference 1).  In one study, patients presenting with congestive heart failure and an elevated BNP level were found to have an increased morbidity and mortality in the subsequent 90 days (Reference 2). In conclusion this patient had decompensated congestive heart failure and an elevated BNP level.  Inpatient hospital admission was medically necessary.

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Diabetes mellitus, hypertension, hyperlipidemia, benign prostatic hypertrophy, diabetic neuropathy, hyponatremia, left knee pain, and foot pain.
Treatment: PCA level 2: 10 hours per day, 4 days per week; 7 hours per day, 3 days per week for a total of 61 hours per week.
The insurer denied coverage for: PCA level 2: 10 hours per day, 4 days per week; 7 hours per day, 3 days per week for a total of 61 hours per week.
The denial is: Modified 
The patient is seeking coverage for an increase in Personal Care Aide (PCA) level 2: 10 hours per day, 4 days per week; 7 hours per day, 3 days per week for a total of 61 hours per week. The patient was diagnosed with diabetes mellitus, hypertension, hyperlipidemia, difficulty with walking, benign prostatic hypertrophy, diabetic neuropathy, hyponatremia, left knee pain, and foot pain.

Per the son, the patient did not have the ability to for self-care. The patient was not safe to change or pull-up by themselves. The patient would not eat dinner if no one was there. The patient did not take showers daily. The patient did not take their evening medication if they were alone. There was a change in dressing of the lower body which previously required limited assistance and now required extensive assistance. The patient had modified independence with cognitive skills. The patient was alert and oriented x3. The patient's hearing was adequate and there was minimal difficulty with vision. The patient reported feeling occasionally sad due to health conditions. The patient required maximal assistance with meal preparation, total dependence with ordinary housework, extensive assistance with managing finances, stairs, bathing and transportation, dressing of the lower body, walking, locomotion, toilet transfer; Limited assistance with managing medications, personal hygiene, dressing the upper body and phone use, maximal assistance for shopping; The patient required set-up help for bed mobility and eating. The patient required weightbearing assistance with bathing/dressing of lower body due to pain. The patient was frequently incontinent of bladder and continent of bowel. The patient had a very supportive family that was involved in all aspects of the care. 

The patient was homebound and needed home care throughout the day and night. The patient required extensive or maximal assistance with activities of daily living (ADL). The patient had history of multiple falls four times in 2023. The patient was in a social daycare some days of the week. 


Based on the above, the insurer's denial must be modified. 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 Personal Care Aide (PCA) Level 2: 10 hours per day, 4 days per week; 7 hours per day, 3 days per week, a total of 61 hours per week is not substantiated. However, coverage of Personal Care Aide (PCA) level 2: 7 hours per day, 7 days per week for a total of 49 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incontinence.
Treatment: Incontinence liners.
The insurer denied incontinence liners.
The determination is upheld.


This is a female patient being prescribed incontinence liners for the treatment of incontinence. The medical necessity for the service was denied by the health plan.
The health plan denied the request for coverage of liners. The plan allows a maximum of 250 disposable incontinence care products per month. The patient currently receives 125 diapers per month and 125 pull-ups per month. They have therefore reached the benefit limit. The request for disposable liners requires a letter of medical necessity from the prescribing practitioner.
A Uniform Assessment System was completed. The patient was alert and oriented to person only. Cognition was severely impaired. The patient is not able to make any decisions on her own. For instrumental activities of daily living, she requires maximal assistance or total dependence for all. For activities of daily living, she requires maximal assistance or total dependence for all. The patient is incontinent of stool and urine with no control present. There was no pressure ulcer present at the time of evaluation. There were no letters of medical necessity or medical records provided as part of this appeal. At issue is the medical necessity of the requested incontinence liners.
The requested health service of incontinence liners has not been demonstrated to be medically necessary for this patient.
The health plan provides 250 disposable incontinence care products per month. There was no medical justification provided regarding why the patient requires an additional 250 per month. The current allowance provides for changes approximately every 3 hours throughout the day, which is typically appropriate for patients' incontinence care needs. There is insufficient evidence to determine if an additional 250 products are medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Secondary acute myelogenous leukemia
Treatment: Inpatient Hospital
The insurer denied Inpatient Hospital.
The determination is upheld.

This is a male patient with secondary acute myelogenous leukemia who has previously received induction and consolidation therapy. The patient was in complete remission and was admitted for inpatient care for a halo-identical peripheral blood stem cell transplant following fludarabine+cyclophosphamide+total body irradiation (TBI). Inpatient care is under review for medical necessity.
Continued hospital admission was not medically necessary for this patient.
During the period under review, the patient was not transfusion dependent and was able to take nutrition and fluids orally. He had no evidence of severe organ dysfunction. He had no clinical or laboratory evidence of an active infection. He did not have evidence of graft versus host disease that required inpatient therapy. He had no evidence of leukemic relapse nor of graft failure nor of engraftment syndrome. His vital signs remained stable throughout this period and he was not febrile. For these reasons, literature supporting inpatient admission for the dates of service (DOS) under review is not available.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unequal pupils

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is a male child brought to the emergency room due to his mother noticing he had unequal pupils. Examination found left sided mydriasis and partial ptosis. Pupils were reactive to light bilaterally, normal extraocular eye movements bilaterally, normal convergence, no afferent pupillary defect, no photophobia. No falls and no change in vision were reported. He had a recent visit to Italy and reported being bitten by mosquitos. He denies tick bites. The patient was admitted to pediatric unit for further observation and evaluation with diagnosis of Horner's Syndrome and Ptosis. Ophthalmology recommended magnetic resonance imaging (MRI). The record notes difficulty to get this at night due to staffing issues. Differential diagnosis included Horner's syndrome, tumor of the sympathetic chain, ocular myasthenia graves, space occupying brain lesion, space occupying lesion of the chest, exposure to topical cycloplegic drug, Lyme disease. He uses atropine drops for myopia/strabismus which he self-administers. 

Laboratory tests showed mildly elevated white blood cell (WBC) count at 13.3, red blood cell (RBC) count 5.07. On day of discharge the provider noted no neurological deficit, no ptosis, and the left pupil looking very similar to the right one with a diameter of 3-4mm. Magnetic resonance imaging (MRI) noted unremarkable findings. Myasthenia gravis blood work was requested for follow-up at outpatient clinic. Note to stop atropine drops and patient cleared for discharge. Cause of symptoms was most likely caused by atropine administration. 

Milliman Care Guidelines (MCG) notes hospital admission is needed for appropriate care of an individual who presents with ocular or visual findings (e.g., diplopia, reduced visual acuity, abnormal ocular examination) with suspected etiology that requires evaluation or treatment beyond scope of observation care (e.g., central nervous system (CNS) infection, vascular abnormality, Wernicke encephalopathy). Sensitivity to light and mydriasis were reported in 1% of atropine-treated patients. Horner's Syndrome classically consists of ptosis, miosis, and sometimes anhidrosis. It results from damage to the oculosympathetic pathway, which extends from the hypothalamus to the eye.

The review of guidelines, clinical, and literature review found that the cause of his mydriasis and partial ptosis was more than likely due to his atropine drops; however, the presentation could have been related to other issues. The admission was needed to further evaluate and determine if more serious or underlying causes were present. 

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis. 
Treatment: Physical therapy. 
The insurer denied physical therapy. 
The determination is overturned. 

The patient is a male with diagnoses significant for diabetes and osteomyelitis. At issue is the medical necessity of 6 home health physical therapy visits. 
The requested 6 home health physical therapy visits are medically necessary for this patient. Without skilled physical therapy the patient would be at much a higher risk of falls and further injury. The patient was homebound and needed a skilled therapist in order to improve balance, strength, gait pattern and posture. 
The patient was prescribed 6 home health physical therapy visits. Physical therapy noted bilateral lower extremity strength to be 3 plus (+) to 4 minus (-)/5. The patient was requiring contact guard assistance with ascending and descending steps and ambulated outdoors. His balance was unsteady and the patient was unable to stand unsupported. He was a high fall risk. The patient was doing relatively well and required less assistance with ascending and descending steps. He continued to require verbal cues for proper breathing pattern but was making good progress. He was noted to still be home bound and still requiring verbal cues for proper technique of exercises. He was not yet independent to be discharged from therapy. He had improved with indoor and outdoor ambulation but outdoor with straight cane still required contact guard to minimal assistance and verbal cues. This need for hands on assistance continues to support skilled, home health as the patient is progressing but not yet able to safely walk outdoors and is not fully independent. Physical therapy noted that that the patient had suffered a fall and now had decreased bilateral lower extremity strength, decreased balance and decreased functional mobility. He was homebound. Skilled physical therapy, at home, was medically necessary to improve strength/balance and decrease fall risk. These services could not be performed elsewhere. Skilled therapy was still supported as the patient still required minimum assistance for ascending and descending steps. In addition, outdoor ambulation was minimum assistance and cadence was described as slow with decreased step length - indicating poor strength and balance. Additionally, he was noted to have fatigue post treatment and required verbal cues for proper breathing pattern.
The physical therapy visits were medically necessary and appropriate for this patient with multiple medical problems, poor endurance, muscle weakness and a fall risk. The patient was experiencing pain throughout the sessions supporting skilled modalities. The patient also takes multiple blood thinners placing him at higher risk of injury with a fall - and, as noted, the patient had suffered a fall further supporting continued physical therapy.