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

Diagnosis: Sickle Cell Anemia
Treatment: Ferriprox
The insurer denied the request for Ferriprox.
The health plan's determination is upheld.

The patient is a male with a diagnosis of sickle cell anemia who is receiving chronic monthly blood transfusions. He has had complications to include acute chest syndrome, splenic sequestration, and multiple vaso-occlusive crises. Due to the chronic transfusion therapy, he has been having issues with iron overload. He has recently been treated with Deferasirox at a dose of 17 milligrams per kilogram (mg/kg) per dose, and this has not been effective in lowering his ferritin levels and providing optimal chelation. He had a liver iron concentration measured at 6.1, and at that time he was not receiving any chelation therapy. Ferriprox was requested and denied by insurance, so he was started with Deferasirox at that time. The provider is again requesting authorization for Ferriprox.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The requested health service/treatment of Ferriprox is not medically necessary for the patient. Deferiprone can be used. The patient has iron overload from scheduled monthly blood transfusions as treatment for his sickle cell disease. He has failed treatment with Deferasirox and his provider is currently recommending therapy with Ferriprox. As part of the prior authorization request, there is a notation that Deferiprone was denied for this patient. The reason for this denial is not provided. However, at this time, the request for Ferriprox is being denied, as the provider has not documented trial and failure of the generic Deferiprone product.

While this patient requires chelation therapy, there is no clinical documentation to support the need for the brand name Ferriprox over the generic Deferiprone for the patient. The patient otherwise meets the criteria for chelation therapy given the level of iron overload present in his system. Without clinical documentation to show that Deferiprone has been in fact tried and failed, Ferriprox cannot be approved at this time.

The health plans determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left-hand injury
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is an adult with a history of asthma, gout, hypertension, osteoarthritis, and obesity. The patient presented to the hospital for a scheduled evaluation of a left-hand injury. The date of injury was approximately six weeks prior. The left-hand injury was caused by a saw. At the time of the injury the patient underwent an emergency replantation of the small and ring fingers and replacement of bone loss to the middle finger. During the recent inpatient hospital admission the patient underwent an amputation of the left index finger, ring finger, and small finger. The patient was transferred to the post anesthesia care unit (PACU) after surgery. A splint was made and fitted on the left hand by occupational therapy (OT). Dressing care and follow up instructions were provided. The patient was discharged.

The records show a complex and unique orthopedic procedure was completed. It was of long duration and required use of two flaps for coverage. The procedure was not "simple amputation." Considerable soft tissue reconstruction was completed. Multiple drains were placed. Post-surgical monitoring with Doppler would be essential to determine viability of the flaps. It would be important to evaluate circulatory status on a frequent basis. If a change in status occurred, return to the operating room (OR) might be required. This type of surgery cannot be performed in an ambulatory surgery unit (ASU) or on an ambulatory basis. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease, diabetes, cataracts, dementia
Treatment: Consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level ll, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week
The insurer denied coverage for consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level ll, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week.
The denial is upheld.

This is a geriatric patient with medical problems that include end stage renal disease (dialysis), diabetes, cataracts, and dementia. The patient lives with the spouse in a private residence. The patient is approved for Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week and is requesting additional Personal Care Assistance (PCA) level ll; 8 hours per day, 2 days per week (56 hours per week total).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "modified independent." Performing Instrumental Activities of Daily Living (IADL) tasks varies from limited to maximal assistance. The spouse prepares the meals and informal care is also provided by the sister. The patient requires extensive assistance for bathing, lower body dressing and toilet use. Only limited assistance is needed for upper body dressing and general mobility (locomotion and ambulation). The patient is otherwise independent for bed mobility and eating. The patient is frequently incontinent of bladder and continent of bowel. There has been no change in Activities of Daily Living (ADL) status or falls over the prior 90 days. The clinical condition and functional deficits are not at a level or unpredictable as to require additional PCA, Level ll, 8 hours/day 2 days/week (Saturday, Sunday), total of 56 hours/week. The patient's daughter indicates the patient does not receive any paid caregiver care on the weekends. The patient has the informal care of the spouse and sister on the weekends. In addition, the currently approved CDPAS of 40 hours/week can be flexibly modified and extended over 7 days to better provide for the patient's health and safety in the home. 

From a physical medicine and rehabilitation perspective, the requested CDPAS, 8 hours/day 5 days/week (Monday through Friday) and PCA, Level ll, 8 hours/day 2 days/week (Saturday, Sunday), total of 56 hours/week are not medically 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 Consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level ll, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease, diabetes, cataracts, dementia
Treatment: Consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level II, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week
The insurer denied coverage for consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level II, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week
The denial is upheld.

This is a geriatric patient with medical problems that include end stage renal disease (dialysis), diabetes, cataracts, and dementia. The patient lives with the spouse in a private residence. The patient is approved for Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week and is requesting additional Personal Care Assistance (PCA) level II; 8 hours per day, 2 days per week (56 hours per week total).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "modified independent." Performing Instrumental Activities of Daily Living (IADL) tasks varies from limited to maximal assistance. The spouse prepares the meals and informal care is also provided by the sister. The patient requires extensive assistance for bathing, lower body dressing and toilet use. Only limited assistance is needed for upper body dressing and general mobility (locomotion and ambulation). The patient is otherwise independent for bed mobility and eating. The patient is frequently incontinent of bladder and continent of bowel. There has been no change in Activities of Daily Living (ADL) status or falls over the prior 90 days. The clinical condition and functional deficits are not at a level or unpredictable as to require additional PCA, Level II, 8 hours/day 2 days/week (Saturday, Sunday), total of 56 hours/week. The patient's daughter indicates the patient does not receive any paid caregiver care on the weekends. The patient has the informal care of the spouse and sister on the weekends. In addition, the currently approved CDPAS of 40 hours/week can be flexibly modified and extended over 7 days to better provide for the patient's health and safety in the home. 

From a physical medicine and rehabilitation perspective, the requested CDPAS, 8 hours/day 5 days/week (Monday through Friday) and PCA, Level II, 8 hours/day 2 days/week (Saturday, Sunday), total of 56 hours/week are not medically 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 Consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level II, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia, osteoarthritis, rheumatoid arthritis, congestive heart failure, dementia, fractures, hypertension, urinary tract infections and incontinence. 
Treatment: Increase in Level 2 Personal Care Services, per 15 minutes increase from 63 to 91 hour(s) per week. 
The insurer denied coverage of increase in Level 2 Personal Care Services, per 15 minutes increase from 63 to 91 hour(s) per week. 
The denial is overturned. 

This elderly female has extensive medical history associated with functional decline and needs assistance with all daily activities. The patient lives alone. She receives personal care services (PCS) to assist with all activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The patient's daughter provides some informal help, but the daughter's ability to help her mother with most Activities of Daily Living (ADLs) is limited. The daughter reported the patient's condition has declined and needs additional Personal Care Services (PCS) hours. 

Functional status indicates the patient was totally dependent for meal preparation, ordinary housework, managing finances, shopping; she needed maximal assistance for managing medications, phone use, transportation, stairs, equipment management. The patient needed maximal assistance for bathing, personal hygiene, dressing upper/lower body, toilet transfer, toilet use, walking, locomotion (primary mode of locomotion is with wheelchair, wheeled by others); extensive assistance for bed mobility; limited assistance for eating.
 
The patient had short term and procedural memory problem; was oriented to person; had periods of confusion; was unable to activate emergency plan. 

The patient was unable to report severity of pain with a pain scale. Ability to express pain verbally may decline as cognitive impairment progresses. The patient has limited (if any) ability for self-help with pain relief (e.g., medications; repositioning); and so, a caregiver is needed to help manage pain when it occurs.  

The patient needs maximal assistance for toilet transfer and toilet use; and she has frequent urinary incontinence. 

The patient has history of urinary tract infection (UTI) and is at high risk for pressure ulcers; her risk factors include impaired bed mobility incontinence, impaired nutrition. The hospice nurse noted frequent repositioning is required to prevent skin damage; noting that the patient's skin is very fragile. 

The patient needs a caregiver through the day to help encourage and maintain adequate food and fluid intake each day.

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 Level 2 Personal Care Services, per 15 minutes increase to 91 hour(s) per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure. 
Treatment: Personal Care Aide Hours: 7 Days per Week, 12 Hours per Day (84 Hours per Week). 
The insurer denied Personal Care Aide Hours: 7 Days per Week, 12 Hours per Day (84 Hours per Week). 
The health plan's determination is overturned. 

The patient is a female with past medical history of congestive heart failure, anemia, hypertension, diabetes mellitus (DM) type 2, insomnia, depression, anxiety, hypothyroidism, CLL (Chronic Lymphocytic Leukemia), hyperlipidemia, neuralgia, urinary incontinence, and chronic obstructive pulmonary disease (COPD) who had been assigned PCA (personal care aide) services. 

Personal Care Aide Hours: 7 Days per Week, 12 Hours per Day (84 Hours per Week) are medically necessary for this patient. 
There is documentation of worsening medical and functional status requiring an increase in PCA services. The plan assumed the patient had informal help outside of currently assigned PCA services which is not the case. The patient requires at least limited assistance with walking, locomotion, and transfer toilet which are 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 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, PCA services 12 hours/day, 7 days/week, to total 84 hours/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: Medical necessity
Decision: Overturned

Central nervous system
Home health care

Diagnosis: Parkinson's
Treatment: Home health care
The insurer denied Patient Care Aide (PCA) Services: 12 Hours x 2 (Split Shifts), 7 Days per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of Parkinson's disease, dementia, heart disease, hypertension, atrial fibrillation, congestive heart failure, benign prostatic hyperplasia (BPH), urinary incontinence, bowel incontinence, chronic anticoagulation, hyperlipidemia, chronic kidney disease, bunion and severe hammertoe deformities, and gout who had been assigned PCA (personal care aide) services.

Patient Care Aide (PCA) Services: 12 Hours x 2 (Split Shifts), 7 Days per Week is medically necessary for this patient.

There is documentation from the patient's neurologist, PCP (primary care provider), and son of the patient's worsening cognitive and physical functioning. There is documentation from the patient's neurologist and PCP of medical necessity of increased PCA services. In addition, there are overnight care logs documenting activities of daily living (ADL) assistance needs in the overnight hours at least every 3 hours. The patient's overnight assistance needs would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs 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, Patient Care Aide (PCA) Services: 12 Hours x 2 (Split Shifts), 7 Days 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 his own home.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Infected nerves. 
Treatment: D2750 White glass with high gold content crown for teeth 10, 19, 3, 2, 15, 31, 9; 
D3330 Nerve treatment on molar tooth for teeth 19, 3, 2, 15 and 31; 
D6750 White glass with high gold content cap for bridge for teeth 4, 29, 31, 13, 6, 11; 
D6240 False tooth for bridge for teeth 30, 5 and 12; 
D3310 Nerve treatment on front tooth for teeth 9 and 10; 
D3320 Nerve treatment on bicuspid tooth for teeth 4 and 13. 

The health plan denied D2750 White glass with high gold content crown for teeth 10, 19, 3, 2, 15, 31, 9; D3330 Nerve treatment on molar tooth for teeth 19, 3, 2, 15 and 31; D6750 White glass with high gold content cap for bridge for teeth 4, 29, 31, 13, 6, 11; D6240 False tooth for bridge for teeth 30, 5 and 12; D3310 Nerve treatment on front tooth for teeth 9 and 10; D3320 Nerve treatment on bicuspid tooth for teeth 4 and 13. 

The denial is partially overturned. 

The patient is an adult female needing multiple root canal treatments as well as multiple crowns and bridges. The health plan denied coverage as not medically necessary. The denial is being appealed. 

Specifically, crowns on teeth numbers 2, 10, and 19; root canal treatments for teeth numbers 2, 4, 9, 10, 13, 19, and 31; bridge 4, 5, 6 with #5 false tooth; bridge 11, 12, 13 with #12 being a false tooth, bridge 29, 30 and 31 with #30 being a false tooth are medically necessary. Also, a bridge on 4, 5, and 6 means that caps/crowns on #4 and #6, are medically necessary; a bridge on 11, 12 and 13 means a caps/crowns on 11 and 13 are medically necessary; and a bridge on 29, 30 and 31 means caps/crowns on 29 and 31 are medically necessary. 

Single crowns for teeth #s 2, 10 and 19 are coded D2750. Crowns that are part of a bridge, i.e., teeth 4, 6, 11, 13, 29 and 31 are coded D6750. False crowns that are part of a bridge, teeth 5, 12 and 30 are coded D6240. 

Root canal treatment for teeth numbers 3 and 15 are not evidenced by the provided x-rays to be medically necessary. Crowns on teeth numbers 3, 9 and 15 are not evidenced by the provided x-rays to be medically necessary. Additionally, because Tooth 31 is to be used as a part of a bridge, a crown coded as D2750 would not be medically necessary, since it is being approved under the requested D6750 code. 

There are multiple teeth that have infected nerves. These are the teeth that need the root canal treatment. Most of the teeth needing root canals will need a crown (except #9). All these teeth need to be treated instead of extracting them. Extractions are not needed when the tooth can be treated. There are not evidenced to be any teeth that are hopeless and need extraction. The bridges are needed to replace missing teeth and to allow this patient to chew with a complete dentition. The bridges will also prevent further tooth movements (i.e. tilting). 

All of the requested treatment is needed and medically necessary except for the crowns on 3, 9 and 15 (not needed) and root canals on 3 and 15 (not needed).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain in both feet

Treatment: custom shoe inserts (L3020 x 2)

The insurer denied coverage for custom shoe inserts (L3020 x 2)

The denial is overturned


The patient is an adolescent female who presented to her podiatrist with complaints of pain in both feet that also extends to the back with any amount of walking. The patient was sent by her family doctor for evaluation which resulted in recommendation for custom orthotics. Surgical intervention was also discussed in the event that these failed to relieve her discomfort. In the appeal written by her podiatrist it is made clear that the patient does not meet the functional capacity of those individuals her age due to her condition. The patient was diagnosed with flat feet and valgus deformity with posterior tibial tendinitis. 

Custom orthotics play a role prior to and after surgical intervention.  "Children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility.1"  Furthermore, a systematic review found that orthotics "show potential as a treatment method for children with flexible pes planus.2"  As such, it is in the best interest of this young patient to use custom orthotics prior to having to undergo any type of surgical intervention for her ongoing pain and discomfort.

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 custom shoe inserts (L3020 x 2) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hip/groin pain
Treatment: physical therapy
The insurer denied physical therapy. The health plan's determination is upheld. 

This is a patient diagnosed with right hip and groin pain. Records provided show that a request for additional physical therapy was denied by the insurance carrier as the patient has completed 10 physical therapy visits earlier this year without authorization and also completed a total of 30 visits last year for the right hip, groin and elbow pain. The clinical information provided shows the right hip and groin movement with minimal improvement and the patient continues with pain when walking, standing and going up and down stairs without any significant progress made over the course of therapy.

the requested outpatient physical therapy (20 visits) is not medically necessary for this patient.

According to case notes, the patient has had a total of around 70 physical therapy visits over the past 3+ years and there appears to have been no lasting benefit. According to the patient's letter of appeal, there was an exacerbation of symptoms and the patient reports having had some mild improvement in pain but continues with pain and states that pain is too severe to perform a home exercise program. However, if the patient is able to perform exercises at therapy, it would be expected that the same exercises could be performed independently in the home setting and it appears that this is not occurring. The patient is unlikely to make any gains without continuing with these exercises independently at home. The records provided showed minimal objective improvement. Although the patient continues to have pain with activities, there was no significant progress made in prior therapy sessions that would warrant the need for ongoing skilled therapy rather than transitioning to compliance with the daily self-directed home exercise program as instructed in the sessions of physical therapy previously completed.