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

Diagnosis: Heart Failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is a case of a patient with a history of systolic heart failure who presented to the emergency department (ED) with complaints of chest pain and dyspnea. Past medical history includes heart failure with reduced ejection fraction (10-15%), hypertension, diabetes mellitus, and chronic kidney disease. Upon arrival at the hospital, the patient was tachycardic with a pulse of 125 and a blood pressure of 138/85. The physical examination revealed a rapid pulse without other significant abnormalities. A 12-lead electrocardiogram (ECG) showed atrial flutter without ischemic ST or T wave changes. Serum blood testing revealed an elevated pro-B-type natriuretic peptide (22730) and elevated serum troponin (0.117). The chest x-ray (CXR) showed signs of pulmonary vascular congestion consistent with congestive heart failure. The hospital admitted the patient for treatment. Perfusion testing revealed a severely depressed left ventricular ejection fraction (LVEF) with a fixed inferior wall defect. The patient was treated with diuretics and beta blockers and discharged after two days.

The healthcare plan did not act reasonably, with sound medical judgment, nor in the patient's best interest. This patient has a history of heart failure and reduced ejection fraction and presented with chest pain. Serum blood testing and a chest x-ray revealed type II myocardial infarction and acute on chronic congestive heart failure. Upon admission, the patient's ECG revealed atrial flutter, which may have resulted in periods of rapid ventricular rates leading to worsening symptoms. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period showed an average length of stay of three days. (1) This analysis also showed decreased mortality and readmission rates following admissions to the hospital. The current standard of care for patients presenting with symptomatic atrial fibrillation (AF) is hospital admission. (2) In addition to AF, the patient had chest pain and a high pretest probability of significant coronary artery disease. (3) The patient had an elevated History, ECG, Age, Risk Factors, Troponin (HEART) score and appropriately underwent perfusion testing. (4) In conclusion, acute inpatient admission was medically necessary.

Based on the above, the insurer's denial must be reversed. The healthcare plan did not act reasonably, with sound medical judgment, nor in the patient's best interest.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac sarcoidosis
Treatment: Humira
The insurer denied Humira.
The health plan's determination is overturned.

The patient is a female who has a history of cardiac sarcoidosis that is biopsy-confirmed. Treatment with corticosteroids was unsuccessful. The patient also failed a trial of hydroxychloroquine. Subsequent trials of methotrexate and prednisone were likewise ineffective. The patient was then started on Humira, which resulted in some improvement of joint symptoms. 

Humira is medically necessary for this patient.
Humira (Adalimumab) is a fully human anti-TNF (tumor necrosis factor)-alpha monoclonal antibody that specifically inhibits the effect of tumor necrosis factor-alpha (TNF-alpha). Observational studies suggest that adalimumab may be useful in selected patients with pulmonary and extrapulmonary sarcoidosis refractory to glucocorticoid therapy. In one series of seven patients with glucocorticoid-refractory neurosarcoidosis, treatment with adalimumab (with methotrexate in six patients) was associated with symptom relief, regression of neurologic deficits, and a decrease in disease activity on magnetic resonance imaging (MRI).
In this case, the patient has cardiac sarcoidosis that is biopsy-confirmed. She has failed all standard therapy. Therefore, the use of Humira is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.


This is a female patient diagnosed with obesity. This request is for Mounjaro. Her weight was 134.3 kilograms (kg); body mass index (BMI) was 58.11 Her weight was 142 kg. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary alternatives will be ineffective as the patient does not have an approved diagnosis for the formulary alternatives. However, the request for Mounjaro is not consistent with generally accepted standards of medical practice.
The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss [1-3].
Although the medication is only FDA approved for type II diabetes, it has been shown to be safe and effective in the treatment of obesity [4, 5]. The standard of care based on multiple societal guidelines[6-11] recommends treatment with FDA approved treatments for obesity.
However, the patient has not tried and failed medications that are FDA approved for obesity. It is not appropriate to treat a patient with an off label treatment such as Mounjaro without trying an FDA approved treatment for obesity.
The patient is not diagnosed with type II diabetes. The patient is diagnosed with obesity. The formulary alternatives and the requested Mounjaro are FDA approved for Type II diabetes.
Therefore, the request for Mounjaro is not consistent with generally accepted standards of medical practice and is therefore not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Myeloma. 
Treatment: Sarclisa (to be used with bortezomib, lenalidomide and dexamethasone). 
The insurer denied: Sarclisa (to be used with bortezomib, lenalidomide and dexamethasone). 
The denial is upheld. 

The patient is an adult male with multiple myeloma. His provider has requested Sarclisa + Velcade + Revlimid + dexamethasone. Sarclisa was denied coverage by the health plan on the basis of medical necessity. The denial is being appealed. 

The requested Sarclisa is not medically necessary. 

The NCCN (National Comprehensive Cancer Network) does not recognize a regimen of Sarclisa + Revlimid + Velcade + dexamethasone as therapy for multiple myeloma. This regimen is currently under study to treat myeloma and is not routinely used at this time to treat myeloma. Therefore, given the above, the treatment with Sarclisa cannot be established as medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female who was admitted due to 
having three seizure events the day prior to admission. It was noted that she was not on the anti-seizure medications, having previously been on lamotrigine. Computed tomography (CT) of the head did not show any acute process. She underwent continuous electroencephalogram (EEG). The request for inpatient admission was previously denied as it did not meet criteria for level of care. 

The requested health service is medically necessary. 

She had three seizures after having been seizure free for many years and was off lamotrigine. She was at very high risk for status epilepticus as well as sudden unexplained death in epilepsy. This warranted frequent neurologic checks. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inflammatory Bowel Disease and Colitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with hyperlipidemia and diverticulitis, who was admitted with complaints of abdominal pain and fevers. Her temperature was reportedly 102.5 degrees Fahrenheit. Her white blood cell (WBC) count was 19.9. 
Computed tomography (CT) of the abdomen showed sigmoid colitis. The patient was treated with intravenous antibiotics, intravenous fluids, nothing by mouth, and Morphine. On 
day #2, the patient had reported an improvement in pain. On day #4, the patient was reportedly tolerating clear liquids. The patient was discharged the next day. The request for coverage of the inpatient hospital admission is under review. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

This patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for an extended period (e.g., more than 24 hours). 

The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists after observation care; and she did not have suspected toxic mega colon. 
Additionally, the patient did not have bacteremia, and she did not require a procedure that could not have been performed on an ambulatory basis. As such, the requested health service would 
not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who initially presented to the emergency department with concerns of chest and epigastric pain for one week. She had a pertinent history of cardiomyopathy status/post (s/p) automatic implantable cardioverter defibrillator (AICD), congestive heart failure, coronary artery disease, gastritis, breast cancer status/post (s/p) lumpectomy, and hypertension. The initial examination documented the patient as alert and oriented with epigastric tenderness to palpation. An electrocardiogram (EKG) did not reveal acute ischemic changes. A chest x-ray (CXR) was unremarkable. Computed tomography angiography (CTA) of the chest was relatively unremarkable. The patient was admitted to the hospital with an impression of atypical chest pain and chronic co-morbidities. The treatment plan included resumption of home medications and consultations. Cardiology consulted and ruled out acute coronary syndrome and recommended investigating non-cardiac chest pain. Pain management consulted and recommended oral analgesia. Gastroenterology consulted and had an impression of chronic abdominal pain and recommended outpatient follow-up. The patient was discharged. At issue is the medical necessity of an inpatient admission.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient had a history of coronary artery disease, congestive heart failure, and cardiomyopathy who presented with epigastric and chest discomfort of one week duration. The serial troponins, electrocardiogram, chest radiograph, and computed tomography (CT) angiogram of the chest were relatively unremarkable. Cardiology consulted and ruled out acute coronary syndrome. Multiple other consultants evaluated the patient and recommended outpatient follow-up. Treatment was largely supportive and no urgent procedures were indicated or performed.
The clinical indications for admission to inpatient care were not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female who presented to the emergency department (ED) with cough, fever and chest pain for one month.
The patient was seen for the same reason a month before. At that time, she was diagnosed with pneumonia and discharged on antibiotics. Her chest pain was 4/10. Her chest pain and tightness occur only in the setting of cough and deep inspiration, therefore, likely musculoskeletal pain.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with chest pain which was pleuritic in nature. The patient previously was treated for a similar condition. Her work up for pulmonary embolism (PE) and acute coronary syndrome was negative. There was an echo was done in the ED, and a diagnosis of pericardial effusion was made, but the normal echocardiogram did not reveal pericardial effusion. The patient felt to have an upper respiratory infection (URI).
The patient did not have indications for inpatient admission. The only abnormality treated was her elevated BP, and she received intravenous (IV) Labetalol. The rest of her management was not at the level of acute inpatient admission.
A lower level of care would be more appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a female patient with low back pain. She had magnetic resonance imaging (MRI) of the lumbar spine, which shows no acute abnormality, no canal stenosis, multilevel degenerative nerve root contact. The MRI of the lumbar spine demonstrates (L) 4/5 Modic type I changes. The documented diagnosis suggests vertebrogenic pain syndrome. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

According to guidelines and cited references, despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. If approved despite non-recommendation, there should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between lumbar (L) 3 and sacral (S) 1 on magnetic resonance imaging.
According to Becker, et.al : "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)."
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial.
As cited above, the Becker. et.al trial indicated only a 17 patient observational study.
These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures.
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. In addition, no United States guidelines based on research recommend this treatment. As such, the proposed health service or treatment intraosseous basivertebral nerve ablation are not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a female patient diagnosed with low back pain.  She has tried multiple treatments including chiropractic, home exercise, lumbar epidural steroid injections, physical therapy, massage therapy and trigger point injections. Medication has included aspirin. The pain is rated at 9/10 and impacting activities of daily living. The provider states the patient had an magnetic resonance imaging (MRI) scan showing Modic type I changes at disc spaces lumbar (L) 4 - L5 and the provider believes that this is the source of the patient's chronic back pain.
The patient was seen regarding a history of chronic low back pain. She has been receiving epidural injections approximately twice per year for the past 6 years and had some benefit, but recently feels they had not helped at all. She had attempted multiple trigger point injections. The physical examination revealed tenderness at the lumbar paraspinals and lumbar spine, otherwise unremarkable exam. The plan was for the Intracept procedure and this is under review.
The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation (BVN) procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and she was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, the MRI shows multiple findings that are significant and likely pain generators including nerve root impingement from L2 through S1. There are a lack of high quality studies evaluating the long-term risks and benefits of the requested procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

The is a female patient with complaints of chronic low back pain. Prior treatments have included chiropractic care, injections to the lumbar spine, physical therapy as well as medications. The pain significantly impacts activities of daily living (ADLs). The pain can be as high as 9 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type I changes at the disc spaces lumbar (L) 4 and L5. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain.
There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Outpatient facility/anesthesia
The insurer denied outpatient facility/anesthesia.
The determination is overturned.

This is a male with a history of poor dentition and anxiety. He has treatment planned for multiple dental restorations and extractions. Due to his young age, complex dental work, anxiety and behavioral issues, the provider was planning to perform the procedure in an outpatient hospital setting under general anesthesia.
At issue is the medical necessity of the outpatient facility/anesthesia.
The requested health service/treatment of outpatient facility/anesthesia is medically necessary for this patient.
The patient's young age, complex dental work including extractions, anxiety and behavioral issues justify the use of an ambulatory care facility with general anesthesia capabilities as the setting of care. The case is medically necessary and the appropriate setting of care is an outpatient ambulatory care facility with general anesthesia capabilities. It is the standard of care for this outpatient facility/anesthesia to perform anesthesia for patients as in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse.
Treatment:  Substance Abuse Inpatient Rehabilitation.

The insurer denied Substance Abuse Inpatient Rehabilitation.  The health plan's determination is overturned. 

The patient is an adult female who presented for inpatient level substance use disorder rehabilitation treatment to address severe alcohol and cannabis and nicotine (tobacco) use disorders. The patient had no history of withdrawal seizures, delirium tremens, or severe withdrawal symptoms, but did report aggressive outbursts when using alcohol in the context of blackouts and active symptoms of co-occurring psychiatric disorders. Immediately prior to her referral, she had been hospitalized for depression and anxiety associated with a primary diagnosis of post-traumatic stress disorder (PTSD) and complications of the alcohol use disorder.  

Substance Abuse Inpatient Rehabilitation was medically necessary for this patient.
The patient's severity of alcohol use disorder, risk of relapse, and lack of sober supports, severe psychosocial stressors and co-occurring psychiatric disorders did support the medical necessity for an admission and continued treatment at the inpatient level of care in keeping with the application of NY (New York) State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria. The patient could not have been effectively treated at a lower level of care during the time interval under review in keeping with prevailing standards of medical practice, American Society of Addiction Medicine (ASAM) Criteria, published guidelines, and the Scientific Literature.