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

Diagnosis: Dementia, anxiety, depression, coronary artery disease, diabetes, and osteoarthritis
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 44 Hours per Week
The insurer denied Increase Personal Care Aide (PCA) Services for a Total Amount of 44 Hours per Week.
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, anxiety, depression, coronary artery disease, diabetes, and osteoarthritis. Denial of increase personal care aide (PCA) services for a total amount of 44 hours per week is being appealed. The health plan approved six hours per day, three days per week, and four hours per day, three days per week, for a total of 30 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 2 months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances and medications, and shopping; extensive assistance with bathing, personal hygiene, dressing, toileting, and bed mobility; limited assistance with walking and locomotion; and supervision for eating. She has bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with toilet transfer, eating, and bed mobility. A letter from the patient's provider notes the patient has advanced dementia and has more cognitive decline. She has a tendency to go out and get lost. She is a danger when she goes outside unsupervised. More home care hours are recommended.

The Increase Personal Care Aide (PCA) Services for a Total Amount of 44 Hours per Week is 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 increase personal care aide (PCA) services for a total amount of 44 hours per week is being appealed. The health plan approved six hours per day, three days per week, and four hours per day, three days per week, a total of 30 hours per week. This patient has multiple chronic conditions. Uniform Assessment System evaluation completed 2 months ago, shows she requires assistance with all activities of daily living (ADLs), except eating. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with toilet transfer, eating, and bed mobility. The appeal statement notes the patient's dementia is progressing and she wanders. She has significant limitations. Uniform Assessment System evaluations show there has been a decline in the patient's level of functioning. The approved personal care aide of 30 hours per week is insufficient to meet the patient's needs as noted above. 
The requested increase to 44 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Achilles tightness.

Treatment: Durable Medical Equipment.

The insurer denied coverage for: Durable Medical Equipment.

The denial is: Overturned.

This is a female child with bilateral lower extremity short Achilles tendons. The patient reportedly began toe-walking approximately 2-3 years ago. The treating physician recommended durable medical equipment (L1970x2, L2280x2, L2220x4, L2755x4, L2270x2); which is currently under review.  

The reviewer agrees the requested durable medical equipment (L1970x2, L2280x2, L2220x4, L2755x4, L2270x2); bilateral (hinged) ankle foot orthoses (lower extremity braces) is clinically appropriate and medically necessary. The patient began toe walking and according to the treating physician has bilateral Achilles tightness, albeit not a fixed contracture. However, the treating physician's recommended physical therapy and ankle foot orthoses are clinically appropriate, medically necessary and the standard care for this patient. This physician also agrees with the treating prosthetist regarding the clinically appropriateness of hinged and not fixed bilateral ankle foot orthoses.  

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 medical equipment (L1970 x2, L2280 x2, L2220 x 4, L2275 x 2, L2270 x 2) is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure (64628)
The insurer denied: Intracept Procedure (64628)
The denial is upheld.

The patient is an adult male with low back pain which began several years ago. His past treatments include lumbar fusion with subsequent revision and extension of fusion, facet injections/medial branch blocks, physical therapy, home exercise, epidural injections, Percocet, and Tylenol. The patient's pain ranges from 8/10 to 10/10. MRI (magnetic resonance imaging) of the lumbar spine shows post-surgical changes of L3-L5 L3 (lumbar) fusion and degenerative changes with progression above the fusion at L2-3. The request for L2 and L3 Intracept procedure was denied coverage by the health plan, as there is not enough proof it improves health, and therefore the health plan deemed it investigational. The denial is being appealed.

The health plan should not cover the proposed treatment.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such the health plan should not cover the Intracept procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure (64628)
The insurer denied: Intracept Procedure (64628)
The denial is overturned.

The patient is an adult male. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes. The patient has pain and has failed treatment for greater than 6 months. Prior treatments include back surgery, facet injection, home exercises, lumbar epidural steroid injections, medial branch injections as well as physical therapy. Four months ago, the patient presented with low back pain right greater than left aggravated with 
prolonged sitting, standing transition. Lumbar exam revealed decreased range of motion and pain with extension and facet loading, pain with flexion, surgical scar well-healed. Per the MRI (magnetic resonance imaging), it was noted that there were Modic type changes at L2/L3 (lumbar).

The health plan should cover the Intracept procedure.

Based on the documentation provided, the requested Intracept procedure is considered medically appropriate in this case. The patient has a history of chronic low back pain, and despite prior multiple treatments the patient continues to be symptomatic. Prior treatments include back surgery, facet injection, home exercises, lumbar epidural steroid injections, medial branch injections as well as physical therapy. Additionally, MRI (magnetic resonance imaging) had noted Modic type changes. The requested procedure has been FDA (United States Food and Drug Administration) approved for such indications.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure (64628)
The insurer denied: Intracept Procedure (64628)
The denial is upheld.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, and home exercises. The patient has 
failed multiple medications, including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. He has 
failed previous lumbar spine surgery.

The health plan should not cover the Intracept procedure.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is not likely to be more beneficial than standard treatments. The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, and home exercises. The patient has failed multiple medications, including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. He has failed previous lumbar spine surgery.
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 has been shown effective in RCT (randomized controlled trial) with 5-year results. 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. However, the patient in this case is not documented to have failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. In addition, the patient has had multiple back surgeries with instrumented fusion. His diagnosis is more likely related to post-laminectomy syndrome than vertebrogenic back pain. Post-laminectomy syndrome is not an indication for Intracept. 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 sacroiliac injections, and spinal cord stimulation 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: Upheld

Diagnosis: Colon cancer; dyspnea on exertion; fatigue; dry cough
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.  The denial has been upheld. 

The proposed treatment was not medically necessary.

This patient is an adult male with a history of colon cancer who presented to the emergency department with progressive dyspnea on exertion, fatigue, and dry cough.  The hemoglobin was 5.7, down from a baseline of 10-11.  The patient received two units of packed red blood cells (RBCs).  Esophagogastroduodenoscopy (EGD) and colonoscopy were completed during a prior admission which showed gastritis and a hyperplastic polyp of the colon.  

The patient was discharged the day after presentation with a plan for video capsule endoscopy as an outpatient.

Admission was not medically necessary as the patient did not have active and ongoing gastrointestinal bleeding, was not hemodynamically unstable, and did not have bleeding that could not be controlled beyond an observational level of care.  In addition, the patient did not any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

The patient presented and was discharged the very next day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The health plan's determination is overturned. 

The patient is a male who was admitted to the hospital for pneumonia. He had a history of liver transplant, hypertension, chronic kidney disease and alcohol use. On presentation, the patient had complaints of a fever, chills, aches, cough, nausea, and headache. Intravenous (IV) fluids and IV antibiotics were given. A chest x-ray noted right lower lobe infiltrate. The patient was immunosuppressed due to liver transplant medications. Lactic acid was initially elevated but had resolved. The patient's condition improved, and he was stable at discharge.
At issue is the medical necessity of full hospital admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of full hospital admission was medically necessary for this patient.
The patient in question does meet medical necessity for the acute inpatient level of care per current literature and the standard of care. According to Mandell et al., (2007), File (2003), and Musher et al., (2014), the patient had community acquired right lower lobe pneumonia in the setting of being immunocompromised. This is a high-risk condition and would require closer monitoring. Per standard of care, a full hospital admission was medically necessary, and a lower level of care was not appropriate for this immunocompromised patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain. 
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult female. She presented to the hospital with complaints of right flank pain. Her associated symptoms include dysuria and back pain. Her past medical history is significant for kidney stones. On presentation, the patient was afebrile and hemodynamically stable. Examination noted right CVA (costovertebral angle) tenderness. Labs were grossly normal other than an abnormal UA (urinalysis). CT (computed tomography) scan showed an 8-millimeter obstructive calculus in the mid to distal right ureter with mild hydronephrosis. The patient was admitted to the hospital on inpatient status and urology was consulted. The patient underwent ureteroscopy with laser lithotripsy and was discharged home. The medical necessity of the patient's inpatient admission is under review. 

The Inpatient admission was not medically necessary. 

The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis, as it was done the next day. The procedure performed is considered a minimally invasive outpatient procedure. As such, in the absence of a "high risk surgical patient," the patient's care did not warrant acute inpatient admission. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. Observation status for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is overturned.

The patient is an adult male. He has a past medical history of hypertension, diabetes mellitus, and incidental note of pancreatic mass within the tail of the pancreas with presumed metastatic lesions within the liver. He had a history of lower extremity infection status post above knee amputation of the right lower extremity. He was noted to have a pancreatic tail mass on his last admission and was discharged after being treated for an infected stump. He presented to the emergency department for urgent evaluation of severe and progressive abdominal pain with intractable nausea and vomiting. The emergency department physician ordered labs as well as radiologic imaging. The patient was treated with intravenous Zofran and intravenous fluid.
Gastroenterology and hematology/oncology were consulted and recommended computed tomography (CT) of the chest/abdomen/pelvis with contrast. This was performed on day #2 and showed a stable cystic appearing mass of the pancreatic tail with central calcification measuring 1.3 centimeters. On day #3, interventional radiology performed ultrasound-guided segment four liver lesion biopsy. Vascular surgery was consulted for right thigh abscess with drains and recommended to continue drains for three more weeks. The intractable nausea/vomiting was said to have resolved on day #3.

The Inpatient Admission was medically necessary.

The patient required an inpatient level of care due to the need for controlling the nausea/vomiting, the need for addressing the pancreatic mass, and the need for addressing the drains present in the right thigh (stump infection/history of abscess). The medical records do support that the acute inpatient admission was medically necessary. The patient did require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting.
Therefore, based on review of the submitted medical records, the requested inpatient level of care was medically necessary for the dates of service in question, as it required the intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: chest pain/cough.
Treatment: inpatient hospital.
The insurer denied the inpatient hospitalization.
The health plan's determination is overturned. 

The patient is a female with a medical history of hypertension who presented with symptoms of right-sided chest/back/upper quadrant pain, dyspnea, and cough with bloody sputum (hemoptysis). She was found to have acute bilateral pulmonary emboli on computed tomography (CT) chest angiography. She was started on treatment with Lovenox and transitioned to an oral anticoagulant Eliquis.

Inpatient Hospital Admission was medically necessary for this patient.
Based on the severity of illness, intensity of required therapy, and guidelines provided, the inpatient level of care was medically necessary. This patient with a medical history of hypertension presented with symptoms of right-sided chest/back/upper quadrant pain, dyspnea, and cough with bloody sputum (hemoptysis). She was found to have acute bilateral pulmonary emboli on computed tomography (CT)CT chest angiography with pulmonary infarcts. Although, she was afebrile, hemodynamically stable with an oxygen saturation was 100% on room air, she required full dose anticoagulation. She was started on treatment with Lovenox and transitioned to an oral anticoagulant Eliquis. Per the criteria provided, in the setting of hemoptysis and pulmonary infarcts, she would have required an inpatient level of care to monitor for further/worsening of lung hemorrhage/hemoptysis while on the anticoagulation therapy (Lovenox).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has a history of hyperlipidemia, venous ablation, obesity, bilateral hip replacement and fatty liver. The patient complained of right > left lower extremity dull/achy pain associated with heaviness, cramping, tiredness, fatigue and significant swelling and with redness in the right leg. All of the patient's symptoms started after hip replacement. The patient's complained of redness and heat in the right leg with difficulty in walking; the patient noted that long standing periods exacerbated the symptoms and worsened at the end of the day. The patient could not carry on with activities of daily living without discomfort. The patient felt that this discomfort was "life limiting." There was no skin discoloration/breakdown/ulcerations.

Physical examination revealed that all lower extremity pulses were intact. It was felt that the patient had May-Thurner syndrome with partial venous obstruction.

The patient was admitted electively for peripheral venography and possible intervention. The indication on the catheter report was bilateral edema and legs symptoms right > left. Venography showed 60-70%(percent) obstruction of the left common femoral vein and 30% obstruction of the right and left common iliac vein. The left common iliac vein showed by intravascular ultrasound a 59% cross-sectional area reduction. Asperex mechanical thrombectomy of the left common femoral was performed followed by balloon angioplasty with an 8 millimeter (mm) diameter balloon. Final angiography was said to show an excellent result.

The patient was admitted, observed uneventfully overnight, and discharged.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. It was reasonable to observe the patient for several hours after intervention to assure no bleeding or other problems. This could have been accomplished by observation for several hours with same day discharge or at most overnight observation as was done. A full admission was not necessary.

As noted above, the admission is considered not medically necessary. It was reasonable to observe the patient for several hours after intervention to assure no bleeding or other problems. This could have been accomplished by observation for several hours with same day discharge or at most overnight observation as was done. A full admission was not necessary.

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 the inpatient admission is not substantiated.