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

Diagnosis: s/p (status post) back surgery
Treatment: personal care assistance services, a total of 70 hours per week
The insurer denied personal care assistance services, a total of 70 hours per week.
The determination is upheld.

This is a patient with a medical history notable for spinal stenosis status post multiple surgical interventions, amnesia, major depressive disorder, and dementia/memory issues. The patient was approved for 35 hours per week of personal care assistance. The patient requested an increase to 70 hours per week, and this increase was denied by the health plan and is under review.

A letter of support for this appeal was provided by the patient's treating neurologist. The letter states that the patient's health and overall status have been deteriorating gradually. 
A letter of support for this appeal was also provided by the patient's primary care physician. The letter describes the most recent office visit  where she continues to have significant pain related to her back. The letter states that she "needs supervision and assistance to avoid additional complications." There is no specific request for additional hours, or discussion of personal care needs that are not currently being met by her allotment of hours.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to be alert and oriented but forgetful. MMSE score was 11/30. For her functional status, she requires maximal assistance for meal preparation and housework. She requires extensive assistance for managing finances, managing medications, and shopping. She requires limited assistance for phone use. For her activities of daily living, she requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility and eating. She is frequently incontinent of urine and uses 1-2 liners daily. She uses a straight catheter as needed due to a history of neurogenic bladder. She is continent of stool. A task tool associated with the assessment recommended 26.3 hours per week to address her personal care needs.

The requested health service/treatment of personal care assistance services, a total of 70 hours per week is not medically necessary for this patient.

The patient has some functional limitations related to her spinal stenosis and associated mobility issues and chronic pain. These functional limitations are currently being addressed by having personal care assistance for 35 hours per week, which represents a 33% increase over the hours recommended by the tasking tool. There is no demonstrated medical necessity provided for increased hours, or evidence of unmet personal care needs that would necessitate an increase in hours. The health plan recommended skilled nursing for any short term needs related to her post operative state which is appropriate. Additional hours that are intended for safety and supervision alone are not provided by personal care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Mood disorder
Treatment: Fanapt (iloperidone)
The insurer denied Fanapt (iloperidone).
The health plan's determination is overturned.

This case involves a male diagnosed with an unspecified mood disorder and intermittent explosive disorder associated with impulse control problems. The patient has been prescribed Fanapt (iloperidone) 10 milligrams (mg) twice daily to address the symptoms of the mood disorder and impulse control problems. The patient has been prescribed Fanapt with a positive therapeutic effect. The Fanapt is prescribed together with Lexapro, Lamictal, Wellbutrin XL (extended release) and Intuniv ER (extended release) at clinically appropriate dosages.

A formulary exception is indicated for this patient.

In this case, the formulary drugs risperidone and aripiprazole will be or have been ineffective, and the remaining formulary drugs would not be as likely to be as effective as the non-formulary drug, or would have adverse effects with tolerability problems.

As indicated above, Fanapt is considered the best choice of medication in this case scenario referencing the positive therapeutic response. Moreover, to switch to another formulary alternative would be detrimental or cause harm to the patient given the positive therapeutic effect of the current treatment with Fanapt.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decreased Oral Intake
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

The patient is a female who was brought to the emergency department in the afternoon with fussiness and decreased oral intake since awakening at 8:00 in the morning on the day of admission. The patient did not have a fever and she was not vomiting. The patient's vital signs were normal. The emergency department (ED) physician's physical exam documented moist mucus membranes, a normal appearing, non-toxic patient, with clear lungs, no respiratory distress, a soft abdomen and capillary refill was less than two seconds. The impression was 24 hours of decreased feeding and increased fussiness. The patient is well appearing with a benign physical exam. The patient is hemodynamically and clinically stable. The patient had normal labs upon review. The patient was given a normal saline bolus. In the ED, the patient had one large loose stool and was sucking normally on a pacifier, but not taking through mouth (per orem), by mouth, or oral nutrition (po), so the patient was admitted for more intravenous (IV) fluids. Her admission history and physical (H&P) was essentially the same as in the emergency department, but soon after arrival, she started taking po. She was kept overnight and discharged the next day.

The patient is a well appearing, female with less than 24 hours of a reduced oral intake. The vital signs were normal and there were no objective physical or laboratory signs of dehydration. The patient did not have a fever and the laboratory workup was unconcerning for the possibility of serious bacterial infection. The patient was not clinically dehydrated. The patient was mildly "dry" and that concern was managed by giving IV fluid boluses in the emergency department. The patient was sucking well on a pacifier all along, but did not want to suck on a bottle. Outpatient management typically involves small, frequent oral fluid administration via a syringe if the patient is not vigorously taking the bottle before considering hospitalization for "refusal to take po".

This would also be considered before the possibility of becoming dehydrated even though the patient is not currently dehydrated and did not have any electrolyte abnormalities. The patient's fluid maintenance requirements are approximately 26 milliliters (ml) per hour with 30ml being equal to one ounce. This is a relatively small amount of fluid and equals one tablespoon of liquid every half hour that would be necessary to give by syringe or bottle to maintain adequate hydration. There is no evidence this would not be provided at home. The patient started having a po intake not long after admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: humerus fracture.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a girl who fell while jumping on a trampoline and sustained a left Type 3 supracondylar humerus fracture. She was admitted to the hospital and underwent closed reduction and percutaneous pinning of the fracture. She was monitored for a period of time afterward then discharged.

The inpatient stay was medically necessary. A Type 3 supracondylar humerus fracture, particularly a high-energy comminuted fracture such as this one, requires urgent treatment, usually consisting of closed reduction and percutaneous pinning. It is essential to monitor the patient closely for symptoms of ischemia or compartment syndrome, which can require an urgent response including possible return to the operating room for exploration and vascular repair, or other procedures. It would be inappropriate to treat this patient at a lower level of care. An Inpatient hospital admission is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Near Syncope.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history (PMH) of hyperlipidemia, hypertension (HTN), systemic lupus erythematosus (SLE), and obstructive sleep apnea (OSA) who was admitted with complaints of (c/o) lightheadedness. Her vital signs were unremarkable. The physical exam was notable for a normal neurological examination. Lab work was unremarkable. Imaging studies, a computed tomography (CT) scan of the head showed a tiny punctate hemorrhage versus mineralization, a chest x-ray (CXR) showed no acute disease. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with near syncope and a possible intracranial hemorrhage and treated with a radiological work-up, telemetry, transthoracic echocardiogram (TTE), and expert consultation. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The inpatient hospital stay was medically necessary. This patient presented to the emergency department (ED) with c/o lightheadedness and was found to have a possible intracranial hemorrhage on her CT scan. Neurosurgery evaluated the patient and recommended every 2 hour (q2h) neurological checks, vital signs, blood pressure (BP) control, and a repeat CT scan of the head in the morning. This patient had imaging finding suggestive of a potentially life-threatening intracranial hemorrhage and required close clinical monitoring to ensure that any possible clinical deterioration would be caught quickly and that any required acute intervention could be implemented urgently. Overall, although this patient was found to eventually not have an intracerebral hemorrhage (ICH), given the patient's symptoms, radiological findings, and requirement for intense clinical monitoring pending further work-up due to clinical suspicions, treating the patient at a lower level of care would not have been medically appropriate and is not consistent with the neurosurgical clinical monitoring recommendations.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain
Treatment: Surgical Services/Intraosseous Basivertebral Nerve Ablation

The health plan denied the requested Intraosseous Basivertebral Nerve Ablation as experimental/investigational.  The health plan's determination is overturned.

This is a male who has chronic low back pain. His pain is across his lower back, right greater than the left. He denied any leg pain or weakness. His pain is increased by physical activities and is severe enough to have a negative impact on his activities of daily living (ADLs) and quality of life. He had tried pain medications, physical therapy (PT)/home exercise and lumbar spinal injections without improvements. A lumbar spine magnetic resonance imaging (MRI) showed Modic type 1 changes at (lumbar) L4/5 with stable grade 1 L4 on L5 anterolisthesis. This patient was recommended for an Intracept procedure at L4 and L5 levels.

The issue is whether the proposed health service or treatment of an 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.

I overturn the health plan's determination, in whole.

Yes. The intraosseous nerve ablation procedure (Intracept ) was designed to treat low back pain from the vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. His pain is increased by physical activities and severe enough to have a negative impact on his ADLs and quality of life. He had tried pain medications, PT/home exercise and lumbar spinal injections without adequate pain relief. Further interventions are medically necessary to improve his pain and functional level. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is medically necessary as the appropriate next step intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain
Treatment: Surgical Services/Intraosseous Basivertebral Nerve Ablation

The health plan denied the requested Intraosseous Basivertebral Nerve Ablation as experimental/investigational.  The health plan's determination is upheld.

The patient is a male with chronic low back pain. He has been treated with conservative care including medication, exercise, activity modification, and interventional procedures. The treating physician recommended a vertebrobasilar nerve ablation.

At issue is whether the proposed health service or treatment for an 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.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

No. The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation would not likely be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. While a recent study has shown promising results, the limitation of most of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up.

In this case, the proposed treatment of the Intracept procedure is not supported by the literature to offer long term relief, and the treating provider does not offer any specific rationale on how this intervention would offer any long-term relief for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain
Treatment: Surgical Services/Intraosseous Basivertebral Nerve Ablation

The health plan denied the requested Intraosseous Basivertebral Nerve Ablation as experimental/investigational.  The health plan's determination is upheld.

The patient is a male with low back pain. Prior treatments have included home exercises, lumbar injections, as well as multiple medications. The pain impacts activities of daily living (ADLs), such as sleeping. The pain ranges from 6-8/10. A magnetic resonance imaging (MRI) of the lumbar spine demonstrated modic type 1 changes at (lumbar) L4-5. It is noted the patient has vertebrogenic low back pain. The request for Intraosseous Basivertebral Nerve Ablation.

At issue is whether the proposed health service or treatment for an 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.

I uphold the health plan's determination, in whole.

The proposed health service or treatment of an 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 an 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 a treatment modality. In general, there is a 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 of an 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: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: D8080 braces and D8670 monthly visit.

The insurer denied coverage for D8080 braces and D8670 monthly visit.  The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, ectopic eruption, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 30 total points to support orthodontic care. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, HLD report. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 30 points to justify orthodontic care. The dentist scored both anterior crowding and Ectopic eruption. As per the HLD requirements/instructions, the dentist was to score only one of the two conditions, whichever is most severe. This review concurs with the HLD index of the insurer attaining 23 total points (5 overjet, 5 overbite, 10 anterior crowding and 3 labiolingual spread).

Regarding the validity of the HLD Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the D8080 braces and D8670 monthly visit is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status-post right middle cerebral aneurysm (MCA).
Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This case involves an adult female diagnosed with asthma, hypertension, vertigo, hemiplegia, migraines, and was status-post right middle cerebral aneurysm (MCA). She presented to the hospital for scheduled cerebral angiogram and embolization of right MCA aneurysm with Cerus contour device. The inpatient discharge summary noted that the patient previously underwent diagnostic cerebral angiogram that confirmed a broad-based right MCA trifurcation aneurysm and small right A2 (location of aneurysm) aneurysm. The plan was for the patient to undergo elective treatment of the aneurysm consisting of a cerebral angiogram and embolization of the right MCA aneurysm with Cerus contour device. Surgery was completed without complications. Following surgery, she was extubated and underwent routine monitoring. Her pain was managed with oral codeine. At the time of discharge, the patient developed increased pain in the right femoral puncture site and had trace swelling. Venous doppler showed no pseudoaneurysm. Vital signs remained stable, and she was tolerating an oral diet. The patient remained on inpatient status until she was discharged. 

The Milliman Care Guidelines state that inpatient care may be indicated for those individuals undergoing an ambulatory procedure or surgery when there is evidence of severe infection, altered mental status, dangerous arrhythmia, hypotension, hypoxemia, or other serious condition or find that requires preoperative inpatient care. Additionally, inpatient treatment may be indicated for those individuals who are undergoing complex surgical approaches were situation anticipated, the patient is at high anesthetic risk, there is presence of drug-related rest, and adequate outpatient care situation, or when there is a postoperative event, condition, or finding that warrants inpatient stay. The records provided for the review did not support that there were any postoperative complications, nor was the patient undergoing a complex surgical procedure. The patient was hemodynamically stable and was undergoing an ambulatory procedure with no indication as to why inpatient admission was necessary. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colorectal cancer, vascular dementia, macular degeneration and vitreous detachment, osteoporosis
Treatment: Personal care services 12 hours a day, 7 days a week, for a total of 84 hours
The insurer denied coverage for personal care services 12 hours a day, 7 days a week, for a total of 84 hours.
The denial is overturned.

This is an older patient with a history of colorectal cancer, vascular dementia, macular degeneration and vitreous detachment, osteoporosis, degenerative spine disease and multiple falls. In a Medical Condition Letter, the physician writes that the patient is on hospice care and requires assistance with all activities of daily living (ADLs), including 1-person support during ambulation. The patient is spending more time in bed, is eating less and has lost weight in the past months. The patient has recently developed fecal urgency, and requests assistance to use the toilet every 30-60 minutes both day and night. The patient's family assists at night but work during the day. An increase in personal care services from 10 hours/day 7 days a week to 12 hours a day, 7 days a week, for a total of 84 hours is requested.

The medical records show progression of a terminal condition. There is documentation to multi system deterioration including ambulation, mental status, incontinence status and overall body status. The patient is unable to be mobilized by herself and has a great risk of fall. There is no evidence that self-care is possible. The Hospice care level of service with worsening supports the necessity of the additional service. The last date of evaluation would not be applicable based upon the described current clinical status.

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 services 12 hours a day, 7 days a week, for a total of 84 hours is substantiated.