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

Diagnosis: Prediabetes

Treatment: Ozempic 2 milligram/1.5 milliliter Pen

The insurer denied coverage for Ozempic 2 milligram/1.5 milliliter Pen

The denial is upheld

According to the medical records, the patient is a male with a body mass index of 28.71 and prediabetes, with hemoglobin of 5.7. He was seen previously; side effects and risk of liraglutide are reviewed. Apparently the patient was prescribed Ozempic and not liraglutide.

Ozempic is not Food and Drug Administration approved for weight loss. Liraglutide in the form of Saxenda is approved for weight loss in patients with cardiovascular risk and body mass index less than 27. It appears as if the medical was going to prescribe Liraglutide but then prescribed Ozempic.  

"Conclusions: In this study, 3.0 mg of liraglutide, as an adjunct to diet and exercise, was associated with reduced body weight and improved metabolic control." (Pi-Sunyer, X. et al. 2015)

"Conclusion: Liraglutide, with diet and exercise, maintained weight loss achieved by caloric restriction and induced further weight loss over 56 weeks. Improvements in some cardiovascular disease-risk factors were also observed. Liraglutide, prescribed as 3.0 mg per day, holds promise for improving the maintenance of lost weight." (Wadden, T. A. et al. 2015)

"The prevalence of obesity worldwide has nearly doubled since 1980 with current estimates of 2.1 billion in 2013. Overweight and obesity lead to numerous adverse conditions including type 2 diabetes, cardiovascular disease, stroke, and certain cancers. The worldwide spread of obesity and associated comorbidities not only threatens quality of life but also presents a significant economic burden. While bariatric surgery has proven to be a viable treatment option for the morbidly obese, there is clearly a need for less invasive alternatives.  Recent research has suggested that long-acting analogs of the gut hormone, glucagon-like peptide 1 (GLP-1), may have potential as an antiobesity treatment. The GLP-1 receptor agonist, liraglutide (trade name Saxenda), was recently approved by the US Food and Drug Administration as an obesity treatment option and shown in clinical trials to be effective in reducing and sustaining body weight loss. This review presents the basis for GLP-1-based therapies with a specific focus on animal and human studies examining liraglutide's effects on food intake and body weight." (Ladenheim E. E. 2015)                                                         

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  

The insurer's denial of coverage for Ozempic 2 milligram/1.5 milliliter Pen to treat prediabetes is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal calculi
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This female with left renal calculi was admitted after a left percutaneous nephrolithotomy (PCNL).  The surgery was uncomplicated.

Computed tomography imaging demonstrated a small stone in the lower pole.  The nephrostomy tube was removed.  Intravenous (IV) antibiotics and intravenous pain medications were adminsitered.  The patient was afebrile and hemodynamically stable.  The hematocrit was 34.  The white blood cell (WBC) count was 17,000.

No, the proposed inpatient admission was not medically necessary.
An acute inpatient level of care was not medically necessary. If any problems arise post-operatively from this major procedure, then an acute inpatient level of care may be indicated.  Post-operative pain control, monitoring for bleeding/infection and use of antibiotics are required after surgery.  Not infrequently because of bleeding or pain, care is extended to a one day length of acute inpatient care.  However, this patient's case was uncomplicated.  Care can be provided with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a history of peptic disease, iron deficiency anemia and alcohol use who presented with right upper quadrant (RUQ) abdominal/epigastric pain and belching. He admitted to use of meloxicam. There was no evidence of vomiting, hematemesis or melena. He had a previous history of gastric outlet obstruction due to a duodenal ulcer. 

The patient was hemodynamically stable, with a hemoglobin (Hgb) of 7.2 but no evidence of gastrointestinal (GI) bleeding. Computed tomography (CT) scan revealed a dilated stomach, with thickening in the duodenum consistent with duodenitis. The patient was hydrated, and treated with pain medication. His pain had resolved and there was no further vomiting. Hemoglobin was stable at 7.4. The patient was monitored for alcohol withdrawal. Esophagogastroduodenoscopy (EGD) revealed duodenitis and gastritis. The patient's diet was advanced. He was discharged.

No, the inpatient admission was not medically necessary.
As the patient was hemodynamically stable, without vomiting, dehydration, electrolyte abnormalities, sepsis, gastrointestinal (GI) bleeding or intestinal obstruction, inpatient admission was not medically necessary.  The patient could have been cared for at a lower level of care such as observation. The patient was medically stable for esophagogastroduodenoscopy (EGD) and if performed, he would have been medically stable for discharge after the esophagogastroduodenoscopy (EGD). Therefore, as there was no hemodynamic instability vomiting, dehydration, electrolyte abnormalities, sepsis, gastrointestinal bleeding, intestinal obstruction or a need for prolonged nothing by mouth (NPO), acute inpatient hospital stay was not medically necessary.

As above, as acute inpatient hospital stay was not medically necessary; the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic organ prolapse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of pelvic organ prolapse. She was admitted to the hospital on for a cystocele repair, rectocele repair and vaginal vault suspension. The procedure was performed without complications and a minimal blood loss. The patient was admitted to the inpatient floor. She was discharged the following day.

No, the Inpatient admission was not medically necessary.
The medical records and medical literature were thoroughly reviewed. Prolapse of the vaginal apex may be corrected by several procedures. Following surgery, patients may ambulate on the first postoperative day. Occasionally, a patient may complain of severe pain and display sensory or motor neurologic symptoms or both, but these were not reported in this patient. Operative repair of a cystocele is generally performed in conjunction with the repair of all other pelvic support defects. It is unusual for anterior supports of the vagina to relax without an accompanying relaxation of the posterior wall. Repair therefore usually consists of an anterior and posterior colporrhaphy, as in this patient. Operative management of a rectocele (posterior colporrhaphy) is generally performed at the time of an anterior colporrhaphy. All procedures were performed through vaginal incisions.

According to the inpatient records, the patient had progressed to a regular diet, was ambulating without difficulty, had good pain control, had normal bowel sounds and flatus by the end of the first postoperative day. She was afebrile and her vital signs were normal and stable during the entire postoperative period. The patient required non-narcotic IV (intravenous) pain medications for a short period of time, and her pain was satisfactorily controlled with oral pain medications. The patient underwent an uncomplicated pelvic floor procedure. The procedure time was as expected for an uncomplicated procedure. The post-operative period in the recovery room was uncomplicated and the patient's condition was stable, with stable vital signs. The patient was likewise stable on discharge from the recovery room. Stable postoperative patients who have undergone uncomplicated procedures such as this patient do not require inpatient admission. They may be reliably observed, by the standard of care, in an ambulatory or intermediate postoperative care unit prior to their eventual discharge. The patient could have been treated at a unit of lesser level of care rather than an acute inpatient admission. Therefore the treatment did not have to be provided in an inpatient setting, was not within the standard of care and therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder.
Treatment: Inpatient Hospital. 
The insurer denied long term acute care hospital. 
The denial is upheld in whole.

The patient is a female with multiple medical problems including end stage renal disease (ESRD) with renal transplant. She was initially admitted to Long Term Acute Care Hospital (LTACH). This review is for the medical necessity of continued Long Term Acute Care (LTAC) inpatient admission. The services were denied by the health plan based upon lack medical necessity.

The health plan's determination is upheld.

The services were not medically necessary at the LTACH level of care.
The patient is a female with multiple problems stemming from a failed renal transplant secondary to focal segmental glomerulosclerosis (FSGS) originally on peritoneal dialysis failure and subsequent transferred to hemodialysis. The patient had calciphylaxis along with multiple decubitus ulcer pressure wounds. Other medical conditions include coronary artery disease and recurrent episodes of congestive heart failure. It was determined that heart failure episodes were attributed to dietary noncompliance. She has chronic pain and narcotic issues along with hypertension, hypothyroidism and medical noncompliance. She had a prolonged hospitalization subsequent prolonged LTACH admission. She had several episodes of readmission to the hospital for congestive heart failure. Her most pressing issue however is noncompliance which severely limited her disposition to skilled care in transfer from LTACH level of care.
For the date of services listed, her level care was more consistent with skilled level of care than LTACH level of care, she did have multiple problems however they have stabilized. A generalized plan of treatment was determined. The noncompliance of the patient along with other social issues placed one of the biggest barriers to care in regard to her disposition to further care after transitioning from LTACH. According to the social work notes, there were 25 referrals to separate facilities which were all denied due to the patient's previous noncompliance and other issues. It is reasonable say that the patient's medical condition was stabilized to the point that she could have gone to skilled facilities however those options were not available during the date of service requested.
This reviewer understands the difficulty in transferring patients to lower level care when they have many social problems however, from a strict medical standpoint, the level care which was being provided during the date of services was not consistent with LTACH level care and was more consistent with skilled level care. In summary the patient did not need the LTACH level of care and could have been managed at a lower level of care status.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has a history of intractable epilepsy. The patient's episodes began at age 6 with recognizable complex partial seizures at age 8. The patient is currently on Keppra, Trileptal and Folic Acid. The patient was tried on numerous other anti-epileptic medications including Neurontin, Tegretol, Topamax, Lorabid, and Septra.
The patient had an extensive work up including magnetic resonance imaging (MRI) brain with right frontal subcortical dysplasia. She also had electroencephalogram (EEG), video EEG and intracarotid sodium amobarbital procedure (ISAP) or WADA testing.
The patient underwent placement and then removal of bilateral subdural electrodes and cranioplasty. Subsequently in  developed an infection requiring re-exploration and 6 weeks of intravenous (IV) antibiotics.
The patient underwent subdural electrode placement and then removal with responsive neurostimulation (RNS) placement with the NeuroPace generator. The patient underwent replacement of the neurostimulator due to battery depletion. The replacement of the neurostimulator pulse generator is more likely to be beneficial than any standard treatment for this patient's condition of intractable epilepsy.  
The patient's history and documentation provided clearly demonstrates the benefits of this treatment for the patient. Also, as the operative report clearly states, the procedure involved placement of the leads near the seizure focus on the surface of the brain and not in the deep nuclei. The literature supports the procedure performed in a selective group of patients with intractable epilepsy who have undergone proper testing and failed other treatments which this patient has done. The final treatment with responsive neurostimulation appears to have given the patient a more effective treatment and management of seizures. The replacement of the neurostimulator performed in 2018 was to allow the patient to continue with her effective treatment of epilepsy and improved functional life. Since neurostimulator placement, patient has had an improved functional life including no emergency department (ED) visits and no hospitalizations for seizures. The health plan's determination is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

At the time of service the patient had a long history of intractable seizures despite maximal medical attempts to control them. Past seizure history dates back to staring episodes when patient was 6 years old, then clinically apparent seizure activity was noted at age 8 with right eye pain and twitching and mouth drooling. At the time of diagnosis of medically refractory epilepsy, and evaluation for more invasive approaches to control symptoms, the patient was experiencing more than 3 episodes a month despite maximal medical therapy. Patient is maintained on Keppra and Trileptal but had failed Neurontin, Tegretol and Topamax. Patient underwent an extensive evaluation including a normal magnetic resonance imaging (MRI) of the brain, and an electroencephalogram (EEG) that suggested left sided foci that were hard to localize and a Wada test that suggested  a risk for memory decline with a mesial left temporal lobe resection, taking that more traditional option off the table. A multidisciplinary conference diagnosed the patient with treatment resistant partial onset seizure disorder. Patient then underwent several invasive procedures including several craniotomies for implantation of both cortical strip electrodes as well as depth electrodes for monitoring. Patient then underwent implantation of the initial left sided RNS (responsive neural stimulation) system  with a left parietal subdural cortical strip and a depth electrode placed in the left insular region. According to the provider letter this system has worked very well for the patient, markedly reducing seizure frequency, intensity and duration, has led to improved quality of life (QOL) with no hospitalizations or injuries due to falls and has allowed patient to complete education. Yes, the continuation of a functioning RNS system is more likely to be beneficial to the patient than any other standard treatment for the insured's life threatening and disabling seizure disorder. The RNS is generally offered to those patients who have medically refractory seizure disorders, are not suitable for resective surgery (as in this patient) and have foci in one or two areas of the brain (partial onset seizures). The Food and Drug Administration (FDA) approved RNS System (NeuroPace) is the first intracranial closed-loop system providing responsive stimulation directly to one or two seizure foci. Real time abnormal electrographic activity is detected, and an automatic responsive stimulation is triggered thus halting evolving seizure activity from propagating. The health plan's determination is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has complex partial seizures that are medically intractable. The request is for an RNS System NeuroPace stimulator generator replacement and programming.  Thorough history by the patient's provider included all prior testing and medications attempted. Her seizure classification is Complex Partial Seizures with testing also noting a left sided seizure pattern. The patient has tried and failed medical management prior to the initial placement of  RNS System. Without the requested service,  partial onset seizures would return and be detrimental to the patient's  health and quality of life. There are no other standard treatments besides medications, which the patient has already failed. The RNS stimulator is likely to be more beneficial than any standard treatment for the patient's life threatening or disabling condition.
This patient did not undergo deep brain stimulation. Patient has complex partial seizures that were being managed by a previously placed RNS System. Patient needed battery replacement and interrogation. The operative report states a diagnosis of medically refractory epilepsy. According to history and associated studies in the operative report, the patient clearly has complex partial seizures, and RNS is indicated for such. The health plan's determination is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity.

Treatment: Laparoscopic sleeve gastrectomy (code 43775).

The insurer denied coverage for the laparoscopic sleeve gastrectomy (code 43775).

The denial is upheld. 

This is a male patient with a history of morbid obesity and seizure disorder. He had a laparoscopic (lap) band placed with an initial weight of 308 pounds. His nadir was 212 pounds. The patient suffers from dysphagia, sticking and pouch dilation requiring deflation of his lap band. His lap band cannot be deflated to the optimal point of hunger suppression and therefore lap band removal and conversion to sleeve gastrectomy is recommended by the treating provider. The patient has undergone surgical evaluation, as well as nutrition and exercise counseling, and psychological testing. 

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does not meet the medical criteria and indications for bariatric surgery for sleeve gastrectomy. At the most recent visit the patient had a body mass index (BMI) of 35.9 and does not have sleep apnea/obstructive sleep apnea (OSA), diabetes, hypertension or any other co morbidity that would justify bariatric surgery. He has undergone appropriate evaluation including psych, nutrition, and followed a medically supervised program. However, he does not meet the criteria for revision surgery from a lap band to sleeve as he does not have any of the complications that would necessitate revision surgery, or the BMI with co-morbidities to justify a procedure. He does not have obstruction or severe reflux, or severe pouch dilation.

The denial is upheld at this time and coverage should not be provided for lap band removal and revision using sleeve gastrectomy in this patient. Lap band removal and revision to sleeve is standard of care when complications from the lap band have arisen. 

The health care plan did act reasonably and with sound medical judgment as the patient did not meet guidelines for bariatric surgery based upon his BMI and lack of co-morbidities. 

The insurer's denial of coverage for the laparoscopic sleeve gastrectomy (code 43775) is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a woman with a history of hypertension, traumatic brain injury and seizure disorder who presented to the hospital with a chief complaint of being found down on the floor at her apartment. Emergency medical services had previously seen the patient multiple times for frequent falls. She reported that she was drinking alcohol earlier and then fell down the stairs. There was also concerned for loss of continence that may have been seizure related. 

The inpatient hospital care was medically necessary for this patient. She presented with suspected seizures, acute rib fractures, acute fall, and acute alcohol intoxication. Overall, she was at an increased risk of an adverse outcome due to each of these comorbid complications. The patient did leave the hospital against medical advice, but this did not relate to the appropriateness of admitting her to the hospital. Patients with seizures and a history of alcohol abuse may experience recurrent seizures in the setting of non-adherence to neuroleptic medications. Inpatient hospital care is appropriate for a patient with this type of presentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay; Missing teeth
Treatment: D5214 Partial Lower Denture, D2751 White Glass With Metal Crown, Tooth 23, D3310 Nerve Treatment On Front Tooth, Tooth 23, Pre-service
The insurer denied the D5214 Partial Lower Denture, D2751 White Glass With Metal Crown, Tooth 23, D3310 Nerve Treatment On Front Tooth, Tooth 23, Pre-service.
The denial is overturned.

The patient is a female requesting benefits for a root canal procedure, a crown and a partial lower denture.

Yes, the proposed treatment is medically necessary.
Tooth #23 has decay into the nerve requiring a root canal procedure to prevent infection. The tooth is decayed to the point of needing a crown after the root canal procedure. The patient is also missing several lower teeth. A lower partial denture will allow for better mastication of food and therefore better digestion. The root canal, crown and denture are all medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Reyvow. 
The denial is overturned.

The patient is a female who has been under the care of a neurologist for a history of migraine headaches. Her medical history includes but is not limited to rheumatoid arthritis (RA), common variable immune deficiency (CVID), deep vein thrombosis (DVT), non-alcoholic steatohepatitis (NASH), diabetes, and reactive airway disease. Office visit notes from a consult were provided. At that time, she was on Emgality and propranolol for migraine prophylaxis. The patient was noted to have previously trialed frovatriptan, sumatriptan and rizatriptan for the acute treatment of their migraines. There was also a handwritten note on the records stating that the patient had also been on naratriptan and Nurtec. The patient was also noted to have previously trialed samples of Ubrelvy. A request has been made for coverage of Reyvow.

The health plan's determination is overturned.

The patient is noted to have previously taken the following formulary drugs: frovatriptan, sumatriptan and rizatriptan and possibly naratriptan and Nurtec. There have not (yet) been any comparison studies completed to date involving Reyvow and triptans to permit conclusions that the requested drug would afford superior clinical outcomes to the formulary agents. However, given the trial of at least three formulary drugs to date, the patient would have otherwise satisfied their health plan's step therapy requirement(s) for coverage. Furthermore, given her lack of adequate response to trials of triptans to date, a change in acute treatment strategy is appropriate. In as much, the requested drug Reyvow can be determined to be the most appropriate choice for this patient.