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

Diagnosis:  Dementia, hypertension, and osteoarthritis.
Treatment:  Personal Care Aide (PCA) Services: 24 Hours per Day (Split Shift) 7 Days per Week.

The insurer denied: Personal Care Aide (PCA) Services: 24 Hours per Day (Split Shift) 7 Days per Week.  The denial is overturned.

This elderly female patient has medical conditions that include dementia, hypertension, and osteoarthritis. The denial of personal care aide (PCA) services 24 hours per day (split shift) 7 days per week is being appealed. The health plan approved personal care aide live-in per day, 7 days per week. Uniform Assessment System evaluation completed three months ago shows severely impaired cognition and maximal assistance to total dependence with all activities of daily living. She is bedbound. She has bowel and bladder incontinence. She needs help with turning and repositioning. She wakes at night yelling and screaming. A letter from Nurse Practitioner (NP) Feldman notes the patient is nonverbal and bedbound. She has bowel and bladder incontinence. She has a sacrum and ankle pressure ulcers. She needs assistance with position change every two hours and requires constant supervision.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. The denial of personal care aide (PCA) services 24 hours per day (split shift) 7 days per week is being appealed. The health plan approved personal care aide PCA live-in per day, 7 days per week. Uniform Assessment System (UAS) evaluation completed three months ago showed the patient requires maximal assistance to total dependence with all activities of daily living. She is bedbound and incontinent of bowel and bladder. The appeal statements support the patient is dependent with all activities of daily living and requires frequent assistance with turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed personal care aide services 24 hours per day (split shift) 7 days per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity, possible sleep apnea. 
Treatment: Polysomnography age 6 years or older, sleep staging. 
The insurer denied coverage for Polysomnography age 6 years or older, sleep staging. 
The denial is overturned. 

Patient has a Body Mass Index (BMI) of 50 and with snoring/choking/restless sleep. Patient may have obstructive sleep apnea (OSA) and this can pose risk of perioperative morbidity for the metabolic and bariatric surgery (MBS). MBS is associated with remission of type 2 diabetes, prediabetes, hypertension, dyslipidemia, and abnormal kidney function in 65-95% (percent) of patients after MBS. This will reduce future healthcare utilization. For risk stratification and avoiding fatal complications, we need to know the patient's Apnea hypopnea index (AHI) and propensity for central apneas. Also, once we have the split night sleep study we will have the data for treatment of OSA and this can be applied at peri operative period. Hence the medical necessity is met for a split night study. 

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 polysomnography age 6 years or older, sleep staging is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Pain Injection (64483x1, 64484 x1)
The health plan denied Pain Injection (64483x1, 64484 x1). 

The health plan's denial is overturned. 

The patient is an adult female with history of chronic low back pain radiating into both lower extremities with associated weakness. She has tried and failed physical therapy, chiropractic manipulation, acupuncture, Tylenol, NSAIDs (non-steroidal anti-inflammatory drugs) and OTC (over-the-counter) medications.

The patient's MRI (magnetic resonance imaging) Lumbar spine showed mild disc bulge with posterior annular tear at L5/S1. The request was for Right L5 and S1 Transforaminal Epidural Steroid Injections.

The health plan denied coverage of the request, because there is no record of recent tried and failed conservative measure prior to the request for transforaminal epidural steroid injections. The denial is being appealed.

The requested right L5 and S1 Transforaminal Epidural Steroid Injection (codes 64483 and 64484) is medically necessary, based on general standard of care for lumbar radicular pain. The patient's radicular pain is resistant to many conservative measures listed above, including failed physical therapy, chiropractic manipulation, acupuncture, Tylenol, NSAIDs (nonsteroidal anti-inflammatory drugs) and OTC (over-the-counter) medications.

The patient's MRI (magnetic resonance imaging) Lumbar spine showed mild disc bulge with posterior annular tear at L5/S1.

This determination is based on the recommendations of the American Society of Interventional Pain Physicians (ASIPP) (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


The patient presented with abdominal pain that radiated to the right lower quadrant (RLQ). He was afebrile but had hypertension. Localized rebound and guarding were present. The white blood cell (WBC) count was 15.2. The computerized axial tomography (CAT) scan showed a thick-walled hyperemic appendix with mild peri-appendiceal inflammatory changes. Intravenous (IV) antibiotics were given. The leukocytosis resolved and he was discharged on oral antibiotics. 

Medical necessity was determined using Milliman Care Guidelines (MCG) guideline MG-GAS for Gastroenterology. Clinical Indications for admission are discussed for nonoperative management of acute appendicitis. These indications include having a complication such as abscess, perforation, or diffuse peritonitis. Uncomplicated appendicitis is also an indication for admission if there is hemodynamic instability, immunodeficiency, active malignancy, acute kidney failure, or failure of observation care with worsening clinical findings. The patient did not have these conditions. 

This patient had right lower quadrant (RLQ) abdominal pain with inflammation of the appendix. Intravenous (IV) antibiotics were started, and his symptoms improved. He did not have failure to respond to observation care or develop a complication such as an abscess or perforation. He did not meet Milliman Care guidelines (MCG) criteria under Gastroenterology for inpatient care. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a female patient who presented to the emergency department (ED) with the complaint of abdominal pain of 1-day's duration. She was evaluated with an examination, labs, and imaging. This assessment revealed right lower abdominal tenderness and computed tomography (CT) findings of uncomplicated acute appendicitis. The white blood cell count (WBC) count was elevated at 20 thousand (K). Surgical consultation was obtained. The patient was admitted to the hospital and started on intravenous (IV) antibiotics and was treated with a laparoscopic appendectomy for acute appendicitis. The operation was completed without complication. The appendix was noted to be inflamed.
Following surgery, pain control was with oral medications, and she was started on a diet. She was discharged from the hospital with instructions for surgical follow up.
At issue is the medical necessity of an inpatient stay.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated with a lower level of care without need for full inpatient admission.

This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan supported the diagnosis of acute appendicitis. The diagnosis and indication for surgery was established and the patient was initially treated with intravenous (IV) antibiotics. A laparoscopic appendectomy was performed. Following surgery to remove the appendix, she was clinically stable and was tolerating a diet. She was discharged from the hospital.

She was clinically stable at the time of presentation and remained so during the course of care. While she had an elevated heart rate and temperature at the time of initial presentation, she responded favorably and promptly to the prescribed treatment (antibiotics and an appendectomy). A lower level of care would have provided for surgical assessment, provision of antibiotics, surgical care and post-surgical monitoring.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal Stenosis
Treatment: Minimal invasive lumbar decompression (MILD) 
The insurer denied the minimal invasive lumbar decompression (MILD).
The health plan's determination is upheld.

The patient is a female who has a diagnosis of intermittent neurogenic claudication to the central lumbar spinal stenosis. The patient failed conservative measures, such as physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and epidural injections. The pain impacts her activities of daily living (ADL). The pain radiates from the lower back and both hips. The physical examination demonstrated negative facet challenge bilaterally, mild tenderness to palpation lumbar spine. The magnetic resonance imaging (MRI) of the lumbar spine demonstrated lumbar spinal stenosis with ligamentum flavum thickening at lumbar vertebrae (L) 4-5.

The proposed health service or treatment of minimally invasive lumbar decompression is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
A new technique, minimally Invasive Lumbar Decompression (MILD) procedure has been described to treat degenerative lumbar spinal stenosis. This procedure involves inserting a cannula through a six-gauge portal and using tissue and bone sculptors to perform a minimal laminotomy and resect the hypertrophied ligamentum flavum in order to decompress the affected dural sac or nerve roots. This procedure is performed using fluoroscopic guidance with a contralateral oblique view epidurogram to visualize depth of the instruments to maintain safety. This procedure is not supported by medical literature due to lack of long-term data supporting its use over traditional treatments, such as laminectomy. 

The health plan's determination regarding the proposed health service or treatment is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal Stenosis
Treatment: Minimal invasive lumbar decompression (MILD) 
The insurer denied the minimal invasive lumbar decompression (MILD).
The health plan's determination is upheld.

This patient is a female who has low back pain with pain traveling to both hips. Her back pain is aching in nature and increases in intensity as she walks. The intensity of the pain is 8 out of 10 at its worst. She is only able to walk for 5-10 minutes because of this severe pain. She had tried home exercise and physical therapy with no success. Her level of daily activities is significant limited by her persistent pain. She had also tried an epidural steroid injection which did not provide her with significant pain relief. 
The physical examination was unremarkable except for a positive straight leg raise (SLR) on the left side. The magnetic resonance imaging (MRI) revealed moderate stenosis from disc bulge and facet hypertrophy with grade 1 spondylolisthesis at lumbar vertebrae (L)4-5. The patient was recommended to have a minimal invasive lumbar decompression procedure at L4-5 level.

The proposed health service or treatment of minimally invasive lumbar decompression is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has severe pain from spinal stenosis. She had failed extensive conservative treatments. Her pain is severe. Further treatments are medically necessary to improve her pain and function. There are multiple well-designed MILD procedure clinical trials showed long-term improvement in pain and function for patients with spinal stenosis. Given her moderate stenosis with grade 1 spondylolisthesis, the alternative surgical option is lumbar decompression and fusion, which is a major spine surgery associated with significant risks and complications. Therefore, the MILD procedure is the next step intervention.

The health plan's determination is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (status-post surgery)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the hospital with right lower quadrant pain. A computed tomography (CT) scan showed uncomplicated appendicitis. Her white blood cell count 
(WBC) was 12. She was afebrile. Appendectomy was performed, and she was discharged.

The inpatient admission was not medically necessary.

The patient's clinical situation did not meet medical necessity requirements for inpatient admission for diagnosis of acute appendicitis. This patient underwent an uncomplicated appendectomy and was discharged. There was no documentation that supported inpatient admission for the above diagnosis. MCG (Milliman Care) guidelines suggest that this procedure is ambulatory in nature, and there is no documentation that supports necessity for inpatient admission. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I and Class II malocclusion
Treatment: D8080 Braces; D8670 Monthly Visits, D8680 Retainer
The insurer denied D8080 Braces; D8670 Monthly Visits, D8680 Retainer.
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic treatment, including monthly visits and a retainer. The patient has a skeletal Class I and Class II malocclusion with moderate upper and severe lower crowding, right posterior crossbite, and a supernumerary (extra) maxillary incisor. She also has ectopic eruption of her first and second premolars. The health plan denied coverage as not medically necessary. The denial is being appealed.

The requested health service is medically necessary.

The patient has very narrow upper and lower arches and a high palate. This will affect her breathing ability over time since she will not have enough volume of air in her reduced size sinuses. Sleep apnea will probably develop over time because of this. She also has a posterior crossbite with moderate to severe crowding. Due to the incorrect position of many of her teeth, she will not have "canine guidance" or "incisal guidance." This means that during the chewing cycle, all her teeth will traumatically bang into each other and will ultimately cause fractures, loosening, and/or trauma to any number of them. Orthodontic treatment is needed to correct these many problems, and the case has medical necessity. The monthly visits are needed to make sure treatment is progressing properly. The retainers are needed at the end to prevent relapse.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Handicapping Index Score 21
Treatment: Full Braces and Monthly Brace Adjustment Visit
The insurer denied: Full Braces and Monthly Brace Adjustment Visit
The denial is upheld.

The patient is a teenage female requesting orthodontic benefits with monthly visits. The prior denial was due to a handicapping index score below 26.

The proposed treatment is not medically necessary.

The patient does not score high enough on the handicapping index scale to warrant orthodontic treatment and monthly visits. She also does not have a handicapping malocclusion that needs treatment. Her handicapping index score is 21 which is below the threshold score of 26. Photos of her dentition do not show any significant need for treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult with past medical history of anxiety/ depression. Patient presented to emergency department with complaint of left flank pain. Patient required morphine intravenous x2 in emergency room, Toradol/ Zofran also intravenous. Computed tomography scan revealed mild-moderate left hydrouretero-nephrosis to the level of a 4 millimeter (mm) left uretero-vesicular junction stone, white blood cells 13,300, creatinine 0.89. Because of distal stone (4mm) medical expulsive therapy was given. Patient improved on intravenous fluids, medications as needed. She was discharged home with outpatient follow up. 

Per Milliman Care Guidelines (MCG) Health (26th) renal colic and kidney stones: patient fails to meet clinical indications for admission to inpatient care. These include urinary tract infection, acute renal failure, hemodynamic instability, bilateral obstruction, etc. 

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD), Dementia.
Treatment: Increase Personal Care Services to 24 Hours per Day (Split Shift) (Two 12 Hour Shifts) 7 Days a Week totaling 168 Hours.

The insurer denied Increase Personal Care Services to 24 Hours per Day (Split Shift) (Two 12 Hour Shifts) 7 Days a Week totaling 168 Hours.  The denial is overturned.

This patient is an elderly female with medical conditions that include chronic obstructive pulmonary disease (COPD), coronary heart disease, depression, and dementia. The denial of an increase in personal care services to 24 hours per day (split shift), a total of 168 hours, is being appealed. The health plan approved 24 hours per day, live-in, for a total of 91 hours. The Uniform Assessment System evaluation completed 5 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, shopping, bathing, personal hygiene, dressing, walking, locomotion, and toileting; maximal assistance with managing finances and medications; and extensive assistance with eating. The patient is bedbound. She has frequent bowel and bladder incontinence. A letter from the Nurse Practitioner, notes the patient has a pressure injury due to limited mobility. She needs position changes every two hours.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual who needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions and is bedbound. The denial of an increase in personal care services to 24 hours per day (split shift), a total of 168 hours, is being appealed. The health plan approved 24 hours per day, live-in, a total of 91 hours. Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires assistance with all activities of daily living (ADLs), except bed mobility. The appeal statements support the patient requires maximal assistance to total dependence with all activities of daily living, except extensive assistance with eating. She has frequent bowel and bladder incontinence. The appeal statement from the patient's provider notes that the patient requires repositioning every two hours due to current pressure injury. The information provided supports that the patient has continuous needs with repositioning/turning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. Therefore, the proposed increase personal care services to 24 hours per day (split shift), a total of 168 hours, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep Apnea
Treatment: Outpatient Procedure (nerve stimulation 64582 x 1)
The insurer denied: Outpatient Procedure (nerve stimulation 64582 x 1)
The denial is overturned.

The patient is an adult male with sleep apnea. The study from five months ago has AHI (apnea-hypopnea index) of 21.7% and no mixed events. Central apneas are 19% of total. The patient had prior SMR (submucosal resection), turbinectomy and palatopharyngoplasty, and tonsillectomy. The patient has been considered for mandibular surgery. The patient has used a dental appliance in the past. The patient has had desaturation to 71% nadir. DISE (drug induced sleep endoscopy) was without concentric collapse.

The requested health service is medically necessary. 

Clinical criteria include having less than 25% central and mixed apneas. The study from five months ago has AHI (apnea-hypopnea index) of 21.7% and no mixed events. Central apneas are 19% of total. Therefore, patient does meet criteria based on this sleep study. The patient is over 18, has BMI (body mass index) below 35, does not have concentric collapse and has failed PAP (positive airway pressure) therapy. The patient has no other anatomical considerations. Consistent with national guidelines, and based on the sleep study, the patient does meet medical necessity criteria for Inspire hypoglossal nerve stimulation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Pain Injection
The insurer denied the pain injections.
The health plan's determination is overturned.

This patient is a female who has low back pain with radicular pain in the left leg. This patient had more than 8 weeks of physician directed exercise and pain medications including nonsteroidal anti-inflammatory drugs (NSAIDs) without adequate pain relief. Her pain level is 9 out of 10. The magnetic resonance imaging (MRI) showed a large left paracentral disc bulge.

The requested health service/treatment of pain injection is medically necessary. This patient has a large lumbar vertebra (L)4/5 disc herniation with resultant radicular pain. She had failed conservative treatment including physician directed exercise and pain medications including NSAIDs. Her pain is severe. Further treatment options are lumbar transforaminal injections and lumbar discectomy. The surgery of lumbar discectomy is associated with more risks and complications. Given this clinical scenario, left L4 and L5 transforaminal injections are medically necessary as the next treatment.

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