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

Diagnosis: back pain.
Treatment: pain management.
The insurer denied an epidural spinal injection. 
The health plan's determination is upheld. 

This patient has a medical history of endometriosis with chronic abdominal/pelvic pain and chronic back pain. Her pelvic pain resolved after a hysterectomy. For her back pain, she had tried physical therapy (PT), non-steroidal anti-inflammatory drugs (NSAIDs), and chiropractic manipulation with no success. She underwent epidural injections and RFAs (radiofrequency ablation0, which worsened her pain. Physical exam (PE) was unremarkable. Lumbar magnetic resonance imaging (MRI)showed L (lumbar) 4/5 disc bulge with no significant central or foraminal narrowing.

The requested Epidural Steroid Injection (ESI) is not medically necessary for this patient. Prior epidural steroid injections were not effective. Further epidural injections are not medically necessary. This patient has chronic back pain with no prior history of back surgeries. The physical exam (PE) was unremarkable. The magnetic resonance imaging (MRI) revealed no significant central or foraminal narrowing and did not reveal any significant findings that can clearly explain her symptoms. There is no strong clinical evidence to support an ESI in this case at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Cibinqo 100 milligram (mg) Tablet
The insurer denied: Cibinqo 100mg Tablet
The denial is upheld

The patient is an adult male who has been diagnosed with atopic dermatitis. He is being prescribed Cibinqo after having an insufficient response to Dupixent. The plan is denying the request for Cibinqo so the treating provider is appealing the denial. The request was denied because the patient has not had a trial of the preferred Rinvoq.

The proposed treatment with Cibinqo is not medically necessary.

There are no head-to-head studies comparing efficacy of Cibinqo and Rinvoq. Both medications are in the same class and Food and Drug Administration (FDA) approved for the treatment of refractory atopic dermatitis. There is no documentation of contraindications to a trial of Rinvoq. There is no evidence suggesting that the patient would do better on Cibinqo over Rinvoq. Thus, medical necessity of the use of Cibinqo for this patient is not demonstrated at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week.
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week. The health plan's determination is overturned.

This is a female with past medical history of osteoarthritis, depression, anxiety, hypertension, dementia, urinary and bowel incontinence, diabetes mellitus type 2, and post-COVID condition who had been assigned PCA (personal care aide) services.

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week are medically necessary for this patient.
There is documentation by the assessment of an increase in assistance needs with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, bed mobility, and eating when comparing to the previous assessments. There is documentation of worsening cognitive and physical functioning. There is documentation in the hospital records of pressure ulcers with the recommendation for turning and repositioning every 2 hours to avoid worsening of these pressure ulcers. The patient has moderate to severe dementia with a diagnosis of restless leg syndrome and reflexively gets out of bed to alleviate restless leg syndrome symptoms at unpredictable times in the overnight hours for which she would need assistance with walking and locomotion. In addition, should the patient have a fall in the overnight hours, the severity of her dementia would not allow her to be able to call for immediate help. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's care needs in the overnight hours would not allow an aide 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 activities of daily living (ADL) and Instrumental activities of daily living (IADL). 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 per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - 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 her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Home health care / Personal Care HHC - Personal Care Aide 24 Hour(s) per Day (Split Shift). 
The insurer denied Home Care / Personal Care HHC - Personal Care Aide 24 Hour(s) per Day (Split Shift). 
The health plan's determination is overturned. 

The patient is a male with past medical history of Parkinson's disease, urinary incontinence, bowel incontinence, benign prostatic hyperplasia (BPH), chronic anticoagulation, hyperlipidemia, and asthma who had been provided PCA (personal care aide) services 24 hours/day, live in, 7 days/week, based on the assessment performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, bathing, dressing lower body, and locomotion while maximum assistance with tasks of managing medication, personal hygiene, dressing upper body, walking, transfer toilet, and toilet use. With tasks of managing finances, phone use, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating.

Home Care / Personal Care HHC - Personal Care Aide 24 Hour(s) per Day (Split Shift) are medically necessary for this patient.
There is documentation by the assessment of increased assistance needs with tasks of managing finances, phone use, toilet use, and eating. There is documentation from the patient's medical provider of worsening physical functioning of the patient and the medical necessity of increased PCA services. The provider also documented the medical necessity of turning and repositioning every 2 hours as well as frequent incontinence cares in the overnight hours that 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 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, Home Care / Personal Care HHC - Personal Care Aide 24 Hour(s) per Day (Split Shift) 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

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a medical history of chronic pancreatitis, irritable bowel syndrome, gastroesophageal reflux disease (GERD), overactive bladder, and depression. She presented to the emergency department with two weeks of right upper quadrant abdominal pain radiating to her back and diarrhea. Her vital signs were unremarkable. The physical examination was notable for a soft and nondistended abdomen with right upper quadrant and epigastric tenderness. Lab results showed an unremarkable complete blood count and comprehensive metabolic panel, and elevated lipase of 219 units per liter (U/L) (upper limit of normal 60). A computed tomography scan of the abdomen and pelvis showed an unremarkable appearance of the pancreas, lack of radiodense gallstones, and fluid-felt proximal small bowel which may be seen with enteritis or ileus. An ultrasound of the right upper quadrant showed unremarkable bile ducts, lack of gallstones, and lack of gallbladder wall thickening or focal tenderness to suggest acute cholecystitis. She was treated with intravenous fluids, morphine, famotidine, and acetaminophen.
She had pain nausea with food intake. A gastroenterology consultation noted recurrent pancreatitis of unclear etiology and acute diarrhea secondary to infection versus pancreatic insufficiency; the recommendation was complete serologic work-up for causes of pancreatitis, intravenous fluids, advance diet to low-fat as tolerated, supportive care with antiemetics and analgesics, and discharge when tolerating oral intake with follow-up and further work-up including endoscopic ultrasound as outpatient.  At issue is the medical necessity of an inpatient level of care.

The inpatient level of care was medically necessary. The patient had acute pancreatitis, given the abdominal pain and lipase elevated to more than three times the upper limit of normal [1-3]. The patient was appropriately treated, with intravenous fluid administration, and gradual advancement of diet [3-7]. Due to the presence of acute pancreatitis without a definite etiology, the inpatient level of care is supported as medically necessary. Per the Milliman Care Guidelines for Abdominal Pain, Undiagnosed, the inpatient level of care is not supported. However, the request would be supported at the inpatient level of care for the treatment of acute pancreatitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations
Treatment: Ambulatory surgery, internal cardiac monitoring
The insurer denied coverage for ambulatory surgery, internal cardiac monitoring.
The denial is overturned.

This is the case of a young adult with a history of palpitations, chest pain and shortness of breath that were first noted following COVID 19 (Coronavirus 2019) infection. Baseline electrocardiogram (ECG) revealed normal sinus rhythm without abnormality. Work up for COVID myocarditis included cardiac magnetic resonance imaging (MRI), exercise stress testing, and echocardiography. She was noted to have a preserved left ventricular ejection fraction and no abnormalities on cardiac MRI or exercise stress testing. Non-sustained ventricular tachycardia (17 beats at 190 beats/minute) was recorded on a 30-day Biotel ECG monitor. Metoprolol therapy was prescribed to treat palpitations, but resulted in side effects of fatigue. An implantable loop recorder (ILR) was recommended to correlate ongoing symptoms with heart rhythm.

This patient suffered from palpitations, chest pain, and shortness of breath. The health plan rejected the implantation of an ILR on the grounds that a 30-day monitor was not worn. The patient's provider provides evidence of a 30-day ECG monitor in the medical records. This study demonstrated a 17-beat run of non-sustained ventricular tachycardia. However, findings did not correlate with the patient symptoms. Additional monitoring would be required to correlate symptoms with findings on ECG. Possible etiologies include symptoms not related to arrhythmia versus symptoms correlating with periods of supraventricular arrhythmia such as atrial fibrillation or longer periods of ventricular arrhythmia. The diagnostic yield of ILRs in patients with palpitations is in the 80-90% (percent) range. (1) Moreover, in one study, ILRs demonstrated a six fold increased detection rate of atrial fibrillation (AF) compared to external ambulatory monitoring. (2). In conclusion, loop recorder implantation is medically necessary in this case, where ambulatory monitoring failed to detect arrhythmia in a patient with hypertension, obstructive sleep apnea, and probable paroxysmal supraventricular tachycardia (SVT) or even AF.

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 ambulatory surgery, internal cardiac monitoring is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gout Flare (polyarthralgia).
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male. He was admitted for worsening joint pain. He was diagnosed with gout flare which responded to conservative therapy. He was also noted to have elevated creatinine, which responded to IV (intravenous) fluid. He was discharged in stable condition on Day #5.

The Inpatient admission was not medically necessary.

The patient was hemodynamically stable, with normal oxygenation and negative cultures. He did not have significant electrolytes disturbance or change in kidney function. He did not have cardiac arrhythmias. He had no persistent nausea and vomiting with dehydration. There was no documentation of refractory pain. The patient was able to tolerate oral diet and did not require total parenteral nutrition. His condition responded to intravenous fluid and antibiotics. An open label, randomized, controlled, non-inferiority trial of 1,054 patients with bone and joint infections found that oral antibiotic therapy was non-inferior to intravenous antibiotic therapy when used after 7 days of antibiotic treatment to complete 6 weeks of treatment [1].
Database analysis of 40,433 patients admitted with a primary diagnosis of arthritis found that 25% were discharged in 3 days or less [2]. Analysis of national hospital discharge data for an adult population shows 39% of hospitalized patients with the principal diagnosis of arthritis discharged in 3 days or less [3].
Therefore, given the above, the patient's condition could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

REVISED 4-7-23

Diagnosis: Elderly person with chronic medical problems including hypertension, asthma and depression

Treatment : Home health services

The insurer denied coverage for 7 days x 24 hours live-in personal care assistance service

The insurer's denial was overturned.

This is an elderly person with chronic medical problems including hypertension, asthma and depression.   She had been living alone in a private residence and is reportedly now residing in a skilled nursing facility (SNF).  The insurer approved PCA services 8 hours per/day, 7 days/week and the request is for PCA services 7 days/week, 24 hours/day, live in; (91 hours/week). 

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as minimally impaired.  She reportedly requires maximal assistance to total dependence for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She requires maximal assistance for bathing.  Extensive assistance is needed for lower body dressing and toilet transfer/use.  She is frequently incontinent of urine and infrequently incontinent of bowel.  Limited assistance is needed for personal hygiene, upper body dressing, locomotion and ambulation.  She is independent with bed mobility and eating.

The patient's medical condition, physical limitations and functional ability are at the level or unpredictable as to require the requested PCA services 24 hours/day live-in.   The letter from the patient's daughter was also reviewed.  According to the daughter her mother is currently in a skilled nursing facility (SNF) with a significant decline in cognitive and functional ability. While the SNF notes were not submitted for review, the fact that the patient fell and was on the floor for 16 hours at home until assistance arrived demonstrates that she is at risk alone and overnight.  

This physician would agree the patient may benefit from additional monitoring; particularly due to her reported cognitive deficits and falls risk.  

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 7 days x 24 hours live-in personal care assistance service services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Issues
Treatment: Braces and Monthly Visits
The insurer denied the request for braces and monthly visits.
The health plan's determination is upheld.

The patient is a male with a Class I occlusion. He has a 6 millimeter (mm) overbite and 3 mm overjet. He has minor maxillary and severe mandibular crowing. He is treatment planned for 24 to 36 months of orthodontics to correct his malocclusion.

The health plan has acted in the best interest of this patient. He has crowding but no teeth are impacted. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows that the lower incisors are contacting the cingulum of the upper incisors in occlusion. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) to this patient. There are no anterior or posterior crossbites present.

There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.

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


Diagnosis: pneumonia.
treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is the case of a young male with autism and seizure disorder who presented to the emergency department (ED) with fever and cough. The symptoms began 4 days prior to presentation. Review of symptoms (ROS) was otherwise negative. Home medication included oxcarbazepine.

The inpatient hospitalization was not medically necessary for this patient and treatment could have been performed at a lower level of care. This patient came to the ED for evaluation of cough and fever. He was found to have pneumonia. The patient had a fever in the ED with otherwise stable vital signs. He did not require intravenous fluids (IVF) or supplemental oxygen. There were no records indicating the need for a higher level of care at the inpatient level. Thus, care could have been appropriate at a lower level with transition to outpatient treatment.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Class 1 malocclusion and posterior crossbite on the left.
Treatment: braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a female with a Class I malocclusion and a posterior crossbite on the left. She has a mandibular deviation to the left. She has severe crowding with teeth 6, 11, and 22 blocked out. Tooth 7 is in crossbite with tooth 27. The patient has an odontoma in the region apical to tooth 20. 

Braces and Monthly Visits medically necessary for this patient.
There is strong medical evidence that that early correction of unilateral posterior crossbites with a shift reduces the need for future treatment. This patient presents with a posterior crossbite, severe crowding, and constricted arches. She would be an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Orthopedic expansion as part of orthodontic therapy can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Back pain.
treatment:  Pain injection
The insurer denied a pain injection. The health plan's determination is overturned. 

The patient is a male who has a chief compliant of severe right side low back pain with tingling in the foot. This patient has a long-standing history of chronic back pain, S/P (status post) lumbar surgery X 3. He has increased pain with difficulty walking for a week. He had tired physical therapy (PT), non-steroidal anti-inflammatory drugs (NSAIDs) with minimal pain relief. 

The pain injection is medically necessary for this patient. This patient has a history of three lumbar spine surgeries. He has increased pain in the right L (lumbar) 5 and S (sacral) 1 distribution. His pain is severe, and he has difficulty walking. He had previously tried PT and NSAIDs without improvement. L5 and S1 transforaminal epidural injections in this case are medically necessary for pain relief and functional improvement.