Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain; hip pain
Treatment: Spine Surgery
The insurer denied: Spine Surgery
The denial is overturned.

The patient is an adult female with history of chronic pain, facet arthropathy, lumbar degenerative disc disease (DDD), lumbar radiculopathy, neurogenic claudication, and spinal stenosis with radiculopathy. The patient is noted to have ligamentum flavum hypertrophy bilaterally at levels L (lumbar)3-4 and L4-5 to be greater than 2.5 millimeters. The request was for minimally invasive lumbar decompression (MILD) procedure at these levels and was denied coverage by the health plan. The patient has previously tried non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, chiropractic care, duloxetine, and transforaminal epidural steroid injections.

The health plan should cover the requested health service.

This is an adult female with chronic pain partly due to severe lumbar spinal stenosis in the central canal. She has tried conservative therapies including physical therapy, chiropractic care, non-steroidal anti-inflammatory drugs (NSAIDs), duloxetine, and epidural steroid injections. These have failed to provide sufficient relief of the patient's pain. Thus, minimally invasive lumbar decompression (MILD) would be an appropriate next step in the management of this patient's care. Therefore, the health plan should cover the requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain; hip pain
Treatment: Spine Surgery
The insurer denied: Spine Surgery
The denial is denied.

The patient is an adult female with low back and hip pain. Her pain ranges from a 3/10 to 9/10. Past treatments include epidural steroid injection, Synvisc one injection of the hip, Cymbalta, diclofenac, home exercise program, and physical therapy. Magnetic resonance imaging (MRI) of the lumbar spine shows multilevel degenerative disc and joint changes, L4-5 severe central stenosis, L3-4 mild/moderate central stenosis, L1-3 mild central stenosis, and L5-S1 no central stenosis. The request for Percutaneous Discectomy and Image-Guided, Minimally Invasive Decompression - image-guided, minimally invasive, lumbar decompression (MILD) or spinal decompression at bilateral L3-5 was denied coverage by the health plan, as it has not been medically proven to be elective and, therefore, is considered investigational as a technique of spinal canal decompression in patients with spinal stenosis. The denial is being appealed.

The health plan should not cover the requested health service.

The evidence for the use of minimally invasive lumbar decompression (MILD) for treatment of spinal stenosis has been continuously debated. Overall, it is considered that while the procedure is likely safe, there is only modest evidence for effectiveness. The available studies are limited in patient size and/or duration. A 2021 publication of a prospective study does show efficacy and lack of adverse reactions at six months with 155 patients aged 50-80. Based on a 2021 review of the available current scientific literature, the novel interventions for symptomatic lumbar spinal stenosis, such as the MILD (minimally invasive lumbar decompression) Procedure and the Superion interspinous spacer, generally are evidenced to be safe and effective. However, there is not valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other conventional treatments. There is a possibility in the future that these interventions could disrupt current treatment algorithms for lumbar spinal stenosis. However, more studies need to be done. As such, the health plan should not cover the requested health service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient hospital-based inpatient detoxification. 
The insurer denied inpatient hospital-based inpatient detoxification. 
The determination is overturned. 

The patient is an adult male who presented to the emergency department requesting detoxification and was admitted for detoxification and withdrawal management of severe alcohol and stimulant (cocaine) use disorders. 
The patient presented with alcohol withdrawal at the time of admission. Withdrawal symptoms included tremors, sweats, nausea and vomiting, insomnia, irritability, and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 14. The patient has no history of a psychiatric disorder. He had a history of substance-related treatment episodes with relapses. There were no acute medical issues or general medical concerns. 
The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a five-day Valium taper, vitamin replacement therapy, fluid replacement, and medical monitoring; the patient was offered smoking cessation treatment and nicotine replacement. Following his first day of treatment, the patient began to participate in counseling and educational sessions. 
At issue is the medical necessity of inpatient hospital-based inpatient detoxification.
The requested health service/treatment of inpatient hospital-based inpatient detoxification was medically necessary for this patient. 
The patient presented with a diagnosis of severe alcohol and stimulant use disorder with the use of crack cocaine. The presenting clinical features and history and risk for withdrawal seizures and other psychosocial complications of alcohol and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively provided at a lower level of care in this case scenario. 
Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Valium requiring monitoring, as well as comfort medications and vitamins and the availability of nicotine replacement therapy. Thus, the patient did require safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cyst and chronic pelvic pain. 
Treatment: Inpatient Hospital Stay. 
The insurer denied Inpatient Hospital Stay. 
The determination is overturned. 

The patient is a female who underwent a laparoscopic left salpingo-oophorectomy that was converted to an open exploratory laparotomy secondary to pelvic adhesions. She was admitted as an inpatient and progressed well after surgery. She was discharged. The inpatient admission is under review for medical necessity. 

The requested health service/treatment of inpatient admission is medically necessary for this patient. 
The patient had an open (laparotomy) incision with her oophorectomy and lysis of adhesions. She was initially scheduled for laparoscopic surgery that would typically not need inpatient admission, however, the surgery was converted to an open procedure secondary to complications of adhesive disease. This includes a large incision into the peritoneum and has a high risk for surgical complications including hemorrhage, infection and inappropriate fluid shifts. Inpatient admission for 1-3 days is standard of care for an open laparotomy and therefore, the inpatient admission is medically necessary. Nursing care for monitoring, urine output, ambulation, pain control and oral intake is essential and standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: weakness, tremors
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a male with liver cirrhosis who was admitted to the hospital with tremors and instability with ambulation. The tremors occurred at rest. The patient felt a sense of disequilibrium and experienced three falls in the preceding ten days. The patient suffered no injuries and could raise himself into a standing position. The tremors are worsening his ability to lift objects with one hand. Additional symptoms included forgetfulness and decreased energy.
 
Based on the provided documentation, the inpatient hospital admission was not medically necessary. The patient has a chronic medical problem that appears to be worsening. Imaging of the head with a head computed tomography (CT) showed no acute abnormalities. The patient has an alcohol use disorder, which has led to mild hypokalemia, thiamine deficiency, and worsening of underlying tremors. He was evaluated by neurology, who recommended a brain magnetic resonance imaging (MRI), and if normal, he was cleared for discharge and follow-up in the outpatient setting. There is no evidence of stroke or bleeding. There is no evidence of central nervous system (CNS) infection. The patient's mental status appeared stable; there was no evidence of delirium tremens secondary to alcohol withdrawal. There is no documentation supporting the inability to maintain adequate nutrition or hydration. Parkinson's disease was deemed unlikely based on the duration of symptoms. Although the patient's ambulatory ability was affected, no documentation supports the inability to perform ADLs (activities of daily living). There was no evidence of neurologic trauma.
Therefore, the entire workup could be completed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Braces and monthly visits. 
The insurer denied coverage for braces and monthly visits. 
The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, anterior crowding, and ectopic eruption among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 31 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 23 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist completes the second portion of the index arriving at 31 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 braces and monthly visits is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Stroke
Treatment: Surgical procedure (vagus nerve stimulator)
The insurer denied Surgical procedure (vagus nerve stimulator)
The determination is overturned.

According to the submitted medical records, the patient has a listed diagnosis of stroke. The records indicate that the patient sustained an ischemic stroke , presenting with "dense" right hemiplegia secondary to occlusion of the extracranial left ICA (internal carotid artery) extending through the MCA (middle cerebral artery). He was treated with Tenecteplase, followed after development of cerebral edema and midline shift by a decompressive hemicraniectomy. Residual deficits have included expressive difficulties, and right hemiparesis. He has undergone physical therapy. Vagus nerve stimulation (VNS) is requested and is under review.

Yes. The patient failed the standard treatment options, and persists with significant right upper extremity weakness. The requested procedure is Food and Drug Administration (FDA) approved for such deficits, based on the following trials. A study reported by Dawson et al, including 108 patients, stated that "vagus nerve stimulation paired with rehabilitation is a novel potential treatment option for people with long-term moderate-to-severe arm impairment after ischemic stroke". One year follow up reported by the same group concluded that "VNS combined with rehabilitation is feasible, with good long-term adherence, and may improve arm function after ischemic stroke". Subsequent 2- and 3-year follow-ups have shown sustained benefits. In 2021, the FDA approved such treatment modality for patients with persistent upper extremity weakness.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Stroke
Treatment: Surgical procedure (vagus nerve stimulator)
The insurer denied Surgical procedure (vagus nerve stimulator)
The determination is overturned.

This is a male patient with right sided hemiplegia and aphasia. The patient was diagnosed with a stroke. He had a left middle cerebral artery occlusion. He was treated with thrombolytic therapy. The patient required a craniotomy for treatment of malignant cerebral edema. Following acute treatment of the patient's stroke, the patient underwent intensive rehabilitation therapy for aphasia and right sided hemiplegia. The patient did not have significant functional improvement and continues to rely on others for activities of daily living and instrumental activities of daily living. A vagus nerve stimulator (VNS) is requested and is under review.

The documentation shows that the patient has already completed standard treatment and had a suboptimal response to physical and occupational therapy. Despite completing almost one year of physical and occupational therapy, the patient continues to be reliant on others for activities of daily living and instrumental activities of daily living. Studies support the use of vagal nerve stimulation after a patient has not progressed with physical therapy after ischemic stroke. One study indicates that VNS paired with rehabilitation may improve upper limb motor and sensory function in patients with chronic stroke. Another analysis of five randomized controlled trials found a significant immediate favoring VNS-based rehabilitation for improving upper extremity function after stroke. In these studies, patients have improved upper limb function and sensory function following placement of a VNS. Given this data, the requested health service is more likely to be beneficial that standard therapy, which the patient has already tried and failed for significant functional improvement.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Stroke
Treatment: Surgical procedure (vagus nerve stimulator)
The insurer denied Surgical procedure (vagus nerve stimulator)
The determination is upheld.

This is a male patient with a history of a right middle cerebral artery (MCA)-stroke. He has had physical therapy and medications without relief. The neurologic exam shows left hemiplegia. The provider has recommended a vagus nerve stimulator (VNS) and this is under review.

No. While this is a promising technology to be used for stroke rehabilitation, further research is recommended. Engineer et al cite, "The studies reviewed provide a compelling demonstration that VNS-based rehabilitation is a potentially useful strategy to target plasticity and improve motor function for chronic stroke". Kimberley et al cite, "This pilot study showed that rehabilitation paired with VNS is an acceptably safe and feasible intervention for the treatment of upper limb weakness after ischemic stroke. The study demonstrated sufficient safety, feasibility, and potential efficacy to support a larger pivotal trial". Ma et al cite, "Although more fundamental and clinical research is still required to fully understand its mechanisms of efficacy, we believe that the frequent and successful clinical use of VNS as a treatment for ischemic stroke is well within reach". Liu et al cite, "The study suggested that VNS combined with rehabilitation therapies offers improving benefits, tolerance and prospect for upper extremity (UE) recovery after stroke. Transcutaneous auricular vagus nerve stimulation (Ta-VNS) technology can reduce the stroke symptoms, providing an alternative technology for patients with stable stroke who are reluctant to opt for other invasive treatments. However, better-designed randomized controlled trial (RCTs), large samples, follow-up and various measures to reflect the restoration of function are needed to confirm our findings in future studies".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Visuospatial deficits, saccadic eye movements, and convergence insufficiency
Treatment: Ten (10) Occupational Therapy Visits
The insurer denied: Ten (10) Occupational Therapy Visits
The denial is overturned.

This patient is a school aged child with history of visuospatial deficits, saccadic eye movements, and convergence insufficiency. The child has a history of cleft lip and cleft palate. The child has been referred to skilled outpatient occupational therapy (OT) services for ongoing concerns with handwriting, attention and concentration. The child has been referred to receive occupational therapy sessions for visual motor integration, ocular motor control, convergence, and pursuits. 
Following review by the health plan medical director, 10 occupational therapy sessions have been denied as not medically necessary. An appeal has been filed by both the mother of the child and the qualified occupational therapist.

The requested health service was medically necessary.

Based on the review of clinical records, the requested occupational therapy services for 10 outpatient occupational therapy (OT) visits to address visual spatial deficits and oculomotor control is medically necessary. This child has achieved short term goals of occupational therapy interventions in outpatient settings. The clinical records point out the lack of any relevant services to address well illustrated concerns and well documented deficits that this child has been struggling with. This is a standard of care based on the clinical needs and evidence in contemporary medical literature. Short term skilled interventions reported improvements in this child's functional abilities. Short term goal-oriented interventions in this case were medically appropriate and should be considered as medically necessary to address the functional needs of this child.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: gastrointestinal bleed
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a female admitted to the hospital. She has a history of Celiac Disease and PCOS (Polycystic ovary syndrome). The patient presented to the emergency room (ER) with dark stool (described in the record as melena in some notes), diarrhea, right lower quadrant (RLQ) pain and palpitations. 

A full hospital admission was medically necessary.
The patient's baseline hemoglobin is in the 14-15 range. She presented volume depleted with a post-hydration Hemoglobin (HGB) of 7.4. This is a dramatic loss of blood. The patient was appropriately resuscitated and required an urgent endoscopy within the first 24 hours of admission. Giving 1 unit of blood was also appropriate. The patient required an inpatient level of management including frequent vital signs and serial hemoglobin values. A lower level of care would not have been safe and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.

Treatment: Wegovy 0.25 mg (milligrams)/0.5 ml (milliliters) SC (subcutaneous) SOAJ (solution auto-injector).

The insurer denied coverage for Wegovy 0.25 mg (milligrams)/0.5 ml (milliliters) SC (subcutaneous) SOAJ (solution auto-injector).

The denial is overturned.

This is an adult female diagnosed with obesity. This request is for Wegovy. She states she has tried and failed nutrition and exercise programs. She had gastric band surgery; she had a vertical sleeve band removed and a vertical sleeve gastrectomy to a single anastomosis duodenal switch. She paid $1300 to test Wegovy and had a successful 14-pound (lb.) loss that month. As per the visit note, she started on Wegovy; she adjusted up to Wegovy 0.25 mg weekly, which she is tolerating well, and she lost 13 lbs. She was provided 2 samples of Wegovy. 

Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer-reviewed medical journals have shown the safety and efficacy of semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy. The standard of care requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI (body mass index) of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, and hyperlipidemia. 

The patient has a BMI of 57.52 and participates in lifestyle modifications, such as diet and exercise. The request is for continuation of therapy and the patient has lost 13 pounds on the requested therapy samples. The request meets the standard of care and is, therefore, medically necessary.

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 patient's best interest. The medical necessity for Wegovy 0.25 mg/0.5 ml, SC SOAJ (solution auto-injector) is substantiated.