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

Dental issues.
Dental procedure.

Diagnosis: missing tooth.
Treatment: Partial Lower Denture (Tooth 18).
The insurer denied Partial Lower Denture (Tooth 18). 
The health plan's determination is overturned. 

The patient is a male who presents for the treatment of missing tooth # (number) 18 with partial removable denture. Provided for review are radiographic images, letters of appeal and denial, a narrative by the patient, American Dental Association (ADA) claim forms, and health plan language.

The Partial lower denture (tooth 18) is medically necessary for this patient.
Based on the provided documentation the patient has missing teeth throughout the maxilla and the mandible, resulting in the diagnosis of partial edentulism. Outside of providing dental implants, the only other way to address the diagnosis is with partial dentures, hence the treatment of partial removable denture is medically necessary to replace the missing teeth and address the diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, frequent falls. 
Treatment: Personal Care Services, 24 Hours a day, 7 Days a Week (Split-Shift). 
The insurer denied Personal Care Services, 24 Hours a day, 7 Days a Week (Split-Shift). The health plan's determination is overturned. 

This is a case review for a female with medical history notable for dementia, history of falls, pressure ulcer of the buttock, and hearing loss. 
The patient's hospice physician provided a letter of support for this appeal. The letter states that the patient has cerebrovascular disease, vascular dementia, and heart disease. She is on hospice care and is expected to have a life expectancy of less than 6 months. Her dementia has advanced, and her speech has become nonsensical. She is not sleeping and does not recognize family members. She is having more falls, especially at night when attempting to toilet without assistance. She is becoming incontinent of bowel and bladder. The physician reports that it is necessary that she have her position changed in bed every 2 hours to help prevent skin breakdown and she requires assistance with changing after episodes of incontinence. 

The requested Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift) is medically necessary for this patient. 
The patient's assessment demonstrates that she requires hands-on assistance for all activities of daily living including toileting. She is incontinent of urine and has now become incontinent of stool as well. The nighttime care logs demonstrate that she requires assistance with changing incontinence products every one to two hours overnight. Furthermore, her physician attests that even if she did not require frequent diaper changes, she would still require changes in position due to prior pressure ulcer of the buttocks. Her care needs are therefore, by definition, continuous and unscheduled throughout the day and night. Split-shift personal care services are appropriate for patients who require continuous care throughout a 24-hour period. Given that the case files demonstrate that the patient's personal care needs are continuous, the requested increase to split-shift services is medically necessary and appropriate for the patient. Failure to address her personal care needs could result in further skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: primary lateral sclerosis
Treatment: home health care
The insurer denied Personal Care Aide: 7 Days x 24 Hours, Split Shifts (Total of 168 Hours per Week). The health plan's determination is overturned. 

The patient is a male with past medical history of primary lateral sclerosis, hyperlipidemia, hypertension, coronary artery disease, diabetes mellitus type 2, depression, osteoarthritis, urinary incontinence, and bowel incontinence who had been assigned PCA (personal care aide) services based on an assessment that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, shopping, and locomotion while maximum assistance with all other tasks. Office notes from noted a stage I sacral ulcer and pressure ulcer on both heels.

Personal Care Aide: 7 Days x 24 Hours, Split Shifts (Total of 168 Hours per Week) are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCA services to split shift. Specifically the provider documented the patient need to be turned and repositioned every 2 hours and the patient required assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL) at unscheduled times throughout the day and night so frequently that an aide would not be able to sleep for 5 consecutive hours. The patient's family documented that they could no longer provide informal help. Overnight care logs documented ADL assistance needs at least every hour overnight. There is documentation in the medical record of pressure ulcers of the heels and sacrum necessitating turning and repositioning every 2 hours for healing and prevention. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the plan suggested an alternating pressure mattress. In the plans denial they stated the patient's incontinence needs could be scheduled which was not the case as documented in the overnight care logs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's assistance needs in the overnight hours are at a frequency that would not allow a PCA 5 hours of uninterrupted sleep. Taking into account clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide: 7 Days x 24 Hours, Split Shifts (Total of 168 Hours 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: Parkinson's Disease, Lymphedema. 
Treatment: Personal care services (PCS) 8-10 hours per day, 7 days a week for a total of 56-70 hours per week. 
The insurer denied coverage for personal care services (PCS) 8-10 hours per day, 7 days a week for a total of 56-70 hours per week. 
The denial is modified. 

The patient is currently authorized for 42 hours a week. The patient has a medical history of Parkinson's disease, urinary frequency, and lymphedema. The patient lives in the independent section of a facility. The patient has some tremors when their medications wear off. The patient has had hyponatremia. The patient's primary care note indicates no falls, ability to get out of bed to toilet once at night. The patient receives Botox injections for foot dystonia. The patient has difficulty with donning their compression socks. The patient has rotator cuff syndrome. The patient does exercise, yoga and physical therapy (PT) at their facility. The patient needs help with preparing meals, housekeeping, laundry, shopping, transferring, bathing, dressing, toileting, medication management, personal hygiene, and eating. 

The patient has mild cognitive impairment. The patient has a medical history of Parkinson's disease, urinary frequency, and lymphedema. The patient needs assistance with her activities of daily living (ADLs). 

The patient has some tremors when their medications wear off. The patient has difficulty with donning her compression socks. The patient has rotator cuff syndrome. The patient needs help with preparing meals, housekeeping, laundry, shopping, transferring, bathing, dressing, toileting, medication management, personal hygiene, and eating. In this case, personal care services are medically necessary. Approval is for 56 PCS hours per week. 

"The activities of daily living (ADLs) is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. The term activities of daily living was first coined by Sidney Katz in 1950. ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs" (1). 

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

The medical necessity for personal care services (PCS) 8-10 hours per day, 7 days a week for a total of 56-70 hours per week services is not substantiated. However, 56 hours of PCS is medically supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: mobility issues and weakness
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day x 7 Days per Week (Split Shift) - Total of 168 Hours per Week.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day x 7 Days per Week (Split Shift) - Total of 168 Hours per Week. The health plan's determination is overturned.

This is a case review for a male with medical history notable for mobility issues and weakness. The patient and his care team requested Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day x 7 Days per Week (Split Shift) - Total of 168 Hours per Week.
The patient's physician provided a letter of support for this appeal. The letter states that the patient is homebound. He suffers from primary lateral sclerosis, idiopathic progressive neuropathy, chronic pain, muscle spasms, generalized weakness, dysarthria, dysphagia, frequent falls, cardiomyopathy, and hypertension. The patient requires assistance with all activities of daily living including bathing, addressing, ambulation, transfers, and toileting. He is incontinent of urine. The patient lives with his wife, but she has health issues as well making caring for her husband difficult and he has very limited informal support.

The requested Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day x 7 Days per Week (Split Shift) - Total of 168 Hours per Week is medically necessary for this patient.
The patient has severe functional limitations as outlined by the Uniform Assessment System (UAS). He requires assistance for essentially all activities of daily living and is not able to complete transfers, ambulation, or toileting without human assistance. He is incontinent of stool and urine. His combination of dementia, incontinence, and inability to complete personal care tasks by himself make the request for continuous personal care services medically necessary and reasonable for the patient. His falls with resulting lacerations and hospitalizations when his personal care aide is not present or evidence of unmet personal care needs. Failure to provide these additional hours could result in additional falls, skin breakdown, and/or infections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dermatomyositis

Treatment: Intravenous Immune Globulin (IVIG) at a dose of 140 grams

The insurer denied coverage for Intravenous Immune Globulin (IVIG) at a dose of 140 grams.

The denial is overturned.

The patient has a diagnosis of dermatomyositis by laboratory tests and clinical symptoms.  The patient has failed therapy with oral steroids and methotrexate and has previously been treated with Intravenous Immune Globulin (IVIG).  The patient has had flares off of IVIG.  The medical care team would like to treat with IVIG at 1 gram per kilogram per day (g/kg/day) (=50 g) days 1-5 as a loading dose followed by a maintenance dose of IVIG 50 g on Day 1 and 2 every 4 weeks.   The patient's weight is approximately 50 Kg.  

Based on the submitted material the use of IVIG is medically appropriate.  Based on the package insert for IVIG, the standard dosing is IVIG 2g/kg divided in equal doses and given over 5 days.  The dosing would equate to 100g total given over 5 days, representing a dosing of 20g IVIG/day.  The patient was initially treated at a dosing of 1g/kg/day x 2 days repeated each month (50g and 50g on two consecutive days).  The documentation indicates that the patient continued to have symptoms and flared despite this dose and supplemental therapies.  The request for a higher than standard dosing is due to clinical determination that the patient did not respond appropriately to the original dosing.  The standard practice in these cases is to either increase the frequency of treatments or increase the overall dosing.  Based on the standard of care, the use of IVIG appears within the standard of care based on the medical determination of the caring physician.  The use of IVIG will require close physician monitoring and laboratory testing.  The use of IVIG at the higher dose recommended by the caring physician is within the standard of care and is approved based on these criteria.  

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

The medical necessity for Intravenous Immune Globulin (IVIG) at a dose of 140 grams is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal Care Assistance services

The insurer denied coverage for Personal Care Assistance services

The denial is overturned

 
The patient is an older adult with a history of dementia. She has had multiple falls, is incontinent of urine and bowels, and is totally dependent with her activities of daily living (ADLs). She is status post (s/p) hip fracture with very limited mobility. Split shift services are requested.

"When friends and family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care" (D'Cruz, L., et al. 2022).

"Millions of older adults and adults with chronic conditions and disabilities in the United States depend on home care workers to remain at home and age in place. Home care workers, which include home health aides, attendants, and personal care aides, provide assistance with personal care (activities of daily living and instrumental activities of daily living), medically oriented care, and emotional support" (Shaw, A. L., et al. 2022).

"The Future of Home Health Care states that one of the 'pillars' of home healthcare should be "patient/person-centered care." They define patient-centered care using the definition in Crossing the Quality Chasm: "Patient-centered care (PCC) is providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" (Institute of Medicine [IOM], 2001, p. 3; Landers et al., 2016, p. 272)" (Narayan M. C. 2022).

The patient has full bowel and bladder incontinence. Total dependence is needed for bathing, personal hygiene, dressing, walking/locomotion, and toilet use/transfers. Extensive assistance is needed for bed mobility and eating. The patient is reported to hardly sleep at night and to try to get out of bed resulting in falls, and to require changing and repositioning. 

In consideration of the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the requested split shift personal care services are medically necessary. 

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 Assistance services, 24 hours per day, 7 days per week (Monday through Sunday), total of 168 hours per week split shift services is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Depression. 
Treatment: Transcranial Magnetic Stimulation (TMS). 

The insurer denied transcranial magnetic stimulation (TMS). The health plan's determination is upheld. 

The patient is a male with diagnosis of major depressive disorder, recurrent moderate whose provider is requesting treatment with transcranial magnetic stimulation (TMS). The progress indicates the patient is interested in TMS for depression and possibly co-existing pain. He reported some stress at work. The patient's affect was noted to be a broad range and appropriate and his mood was dysthymic but less angry and mildly anxious. The plan was to continue the patient's current medications and to refer him for TMS. 

Transcranial magnetic stimulation (TMS) is not likely to be more beneficial than any standard treatment for the insured's life-threatening or disabling condition or disease. The documentation provided is not consistent with a diagnosis of treatment-resistant depression, which is generally defined as a failure of at least two different antidepressants medications of the same or different classes, administered at adequate doses and for an adequate amount of time which fails to produce significant clinical results. The documentation indicates the patient has taken his current medication regimen since last year. While his dose of escitalopram is maximized, his dose of Zyprexa is 5 milligrams (mg), and the maximum recommended daily dose for treatment of major depressive disorder is 20mg. As such, he has not failed treatment with at least two antidepressant medications and cannot be considered treatment-resistant.
Additionally, a review of the medical literature concludes that augmentation with TMS is not significantly better than standard pharmacological augmentation therapies in the treatment of treatment-resistant depression.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Depression. 
treatment: Transcranial Magnetic Stimulation (TMS). 

The insurer denied transcranial magnetic stimulation (TMS). The health plan's determination is overturned. 

The patient is an adult male diagnosed with major depressive disorder, recurrent and severe without psychotic features and treatment refractory/resistant depression. The patient has longstanding depression with depressed mood, anhedonia, and hopelessness, as well as vegetative symptoms of depression and low energy and concentration difficulties. He is diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) -inattentive type and has history of Lyme disease. There is no substance use disorder in this case. 

Transcranial Magnetic Stimulation (TMS) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease with medical certainty. 
TMS is backed by credible scientific study and is consistent with prevailing standards of medical practice for the condition under treatment in this case, recurrent major depressive disorder and treatment refractory/resistant depressive disorder.
TMS can reasonably be expected to provide the patient with greater net health benefit than any other standard therapy in this case scenario. Repetitive TMS therapy as a primary or adjunctive therapy for treatment of depression has generally been evaluated in patients who have had treatment resistant or treatment refractory depression, as defined by one or more, treatment failures with or without augmentation. TMS therapy for depression is established as a safe treatment by the Food and Drug Administration (FDA), and the data as reflected in peer reviewed medical literature supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, or electroconvulsive therapy, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is clinically appropriate. This assertion is also noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Depression. 
Treatment: Transcranial Magnetic Stimulation (TMS)  

The insurer denied transcranial magnetic stimulation (TMS). The health plan's determination is upheld. 

The patient is a male diagnosed with major depressive disorder and has prior trials of Lexapro 20 milligrams (mg), Zyprexa 5mg, Sertaline 100mg, Remeron 15mg, and Clonazepam 0.5mg without benefit. 

These medications indicate a trial of 2 medications in a first antidepressant class (Sertraline/Lexapro), alongside 1 other antidepressant in a second medication class (Remeron). There are no other indications of alternate medication trials including any other within these same trialed classes nor any other medication classes trialed. There is an indication that the patient has trialed psychotherapy for 3 years on a consistent basis. 

TMS is not likely to be more beneficial than standard treatment such as antidepressants. While TMS has been shown to improve depressive concerns indicated with major depressive disorder (as the patient has been diagnosed with), the current generally accepted standards of care and current medical literature still consider TMS not to be standard treatment at this time. As a result, more studies are needed in order to identify TMS as being as efficacious or of more efficacy than standard treatments such as with antidepressants. Currently, there is no indication that the use of TMS for management of major depressive disorder is superior to standard treatment with antidepressants. As a result, the proposed use of TMS for management of major depressive disorder is not likely to be more beneficial than alternate available standard treatments such as with antidepressants.