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

Diagnosis: Low Back Pain.
Treatment: Intracept Surgical Procedure.
The insurer denied: Intracept Surgical Procedure.
The denial is upheld.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, and home exercises. Per the magnetic resonance image (MRI) report, no Modic changes are seen, and there is severe stenosis at L (lumbar) 4-5 and facet arthropathy seen in the low back. The patient's physical exam does not reveal any neurological injury.

The health plan should not cover the proposed treatment.

The requested Intracept procedure should not be covered. The requested health service or procedure is not likely to be more beneficial than standard treatments. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The procedure is an FDA approved procedure for axial low back pain. It has been shown effective in randomized clinical trials (RCT) with five-year results. However, this patient has not failed or attempted all conventional and typical options for common causes of axial low back pain, such as facet and sacroiliac (SI) joint interventions. Furthermore, per the MRI report, no Modic changes are seen. Moreover, the MRI does show severe stenosis that has only been addressed by epidural steroid injections (ESIs) and may be the cause of the axial low back pain and would not be resolved with an Intracept procedure. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis of the denial. Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Surgical Procedure.
The insurer denied: Intracept Surgical Procedure.
The denial is overturned.

The patient is an adult male who has chronic vertebrogenic back pain from Modic type I and II changes at L3, L4 and L5. The patient's pain management physician is seeking approval for an Intracept procedure. The patient has chronic vertebrogenic back pain. The patient has failed conservative therapy such as physical therapy, medical medication management and lumbar epidural injections. The patient's pain level ranges from 4-10 all the way to 9-10. The patient has consistent subjective complaints of pain along with objective physical findings supporting chronic vertebrogenic back pain. Most importantly the patient had a magnetic resonance image of the lumbar spine which showed Modic type I and II changes at L3, L4 and L5 vertebral bodies. The patient has supporting diagnoses supporting clinical indications and approval for an Intracept procedure to treat chronic vertebrogenic back pain at L3, L4 and L5.

The health plan should cover the proposed treatment.

The requested health service and treatment is more beneficial than any standard treatments used for the patient's condition or disease. The patient has failed physical therapy, lumbar epidural injections and medication management. The patient has exhausted all conservative therapy for over one year. The patient has Modic Type I/Type II changes on magnetic resonance image. The Intracept procedure is indicated for Modic Type I/Type II changes. Therefore, the proposed procedure should be covered as the patient meets criteria.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Surgical Procedure.
The insurer denied: Intracept Surgical Procedure.
The denial is upheld.

The patient is an adult male with a history of low back pain which began 2 years ago after a motor vehicle accident (MVA). Past treatments include epidural steroid injections, physical therapy, home exercise program, and Tylenol. Magnetic resonance image (MRI) of the lumbar spine shows multilevel degenerative disc disease with canal and foraminal stenosis. The request for Intracept was denied as experimental/investigational.

The health plan should not cover the proposed treatment.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. 
At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such the health plan should not cover the proposed treatment. 
Other standard treatment options that exist in the medical literature may include: nonopioid medications (i.e. non-steroidal anti-inflammatory drugs [NSAIDs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e. physical therapy, home exercise program, chiropractor treatments) interventions (i.e. epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation), and/or surgical interventions.
Additional studies/trials are necessary to determine efficacy as compared to other conventional therapies. The requested health service or treatment has not been proven to be more beneficial than any standard treatment for the patient's condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with complaints of abdominal pain for 1 day. His white blood cell count (WBC) was elevated at 15.97 and a computed tomography (CT) scan showed a fluid filled appendix. He was admitted to the pediatric unit and taken to the operating room (OR) for a laparoscopic appendectomy with findings of an inflamed appendix. He was discharged. At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary. This patient could be treated at a lower level of care. 

A recent study by Jukic found that same-day discharge after laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way. Therefore, inpatient admission is not warranted.

Another study found that same-day discharge after a laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative length of stay (LOS) and the increase in same day discharge (SDD) are not associated with higher complication rates. (2).
Another study found that same-day discharge for laparoscopic uncomplicated appendectomy should be the new standard of care. The study found no differences in outcomes between the timing of discharge, with a significantly lower cost of stay for patients discharged home the same day. (3)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fetal demise
Treatment: inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

The patient presented to the hospital with complaints of a fetal demise at 18 weeks of gestation. She received Laminaria for cervical dilation and she underwent a dilation and evacuation (D&E). The procedure and postoperative course were unremarkable. The patient was discharged later that day.

This patient presented with a diagnosis of missed abortion at 18 weeks requiring a Dilatation and evacuation. She had Laminaria inserted, and procedure performed.
Most women feel light cramping after the Laminaria insertion. If the cramping is bothersome, Advil, Motrin, or Tylenol will relieve the discomfort.  Many women feel nothing at all. There may be slight bleeding, although a sponge is usually placed in the vagina to hold the Laminaria in place, and it usually retains any bleeding that might occur.

Following Laminaria placement, the patient may go about all her normal activities. She is instructed not to have intercourse, douche, or put anything in the vagina such as a tampon. It is unclear why the patient was admitted for Laminaria insertion. Usually, the Laminaria are inserted as an outpatient and the patient comes back the next day for her dilation and evacuation (D&E). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male with history of hypertension, hyperlipidemia, kidney stone and BPH (benign prostatic hyperplasia). He presented to the emergency department (ED)nwith complaint of right back pain radiating to groin for 1 month, and an inability to ejaculate. The patient reported pain of 6/10 but pain up to 8-9/10 and sharp. The patient presented to the emergency department due to increase in intensity and frequency of the pain. The patient's emergency department evaluation, including US (ultrasound) of the scrotum, demonstrated bilateral hydroceles, left hydrocele with septation, cannot rule out pyocele. A CT (computed tomography) scan was obtained, which demonstrated a large complex right renal mass concerning for malignancy. Laboratory values demonstrated normal white blood cell count, hemoglobin and hematocrit, renal function and urinalysis. The patient was admitted due to the pain, the abnormal CT scan and concern for pyocele. He was started on piperacillin-tazobactam and vancomycin. On presentation to the floor, the patient had severe pain requiring two doses of morphine and ketorolac. The patient's pain was treated with Tylenol, Toradol every 12 hours for moderate pain and morphine 1mg (milligram) every 12 hours for severe pain. An MRI (magnetic resonance imaging) was obtained due to the back pain and ejaculatory failure, which demonstrated mild degenerative changes in lumbar spine, mild bilateral neural foramina narrowing at L3-L4 (lumbar three to lumbar four) and confirmed the large complex cystic mass in right kidney. Oncology, urology and pharmacy were consulted. Pharmacy recommended treating patient with ceftriaxone, doxycycline. Oncology recommended CT of chest, which was performed and demonstrated small nodes. Urology consult recommended partial nephrectomy versus radical nephrectomy and recommended outpatient follow-up to schedule. At the time of discharge, the patient's pain was noted to have improved. 

The Inpatient Hospital Admission was not medically necessary. 

The patient was hemodynamically stable, afebrile with no signs of sepsis, normal renal function, no signs of bleeding and had no other co-morbidities requiring acute inpatient admission. The patient had pain that was increasing in intensity and frequency as well as a large complex right renal mass. The patient could have been evaluated for the renal mass, pain control obtained, and further evaluation of the back pain and ejaculatory dysfunction and pain management at a lower level of 
care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease. 
Treatment: Home health care. 

The insurer denied Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift). The health plan's determination is overturned. 

This is a case review for a female with medical history notable for coronary artery disease, hypertension, hypothyroidism, joint pain, and urinary incontinence. The patient and her care team requested an increase in home health to 24 hours per day (split-shift), and this request was denied by the health plan. 

The patient's physician provided a letter of support for this appeal. The letter states that the patient has had significant cognitive decline. She requires "constant assistance due to her risk of falling" and she needs an aide to help with transfers and getting up at night for toileting. The physician recommends split-shift care services for the patient.

The requested Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is medically necessary for this patient. 

The patient has had a declining functional and cognitive status. She requires hands on assistance for all activities of daily living (ADL) including toileting, transfers, and locomotion. She is approved for live-in care, and the question at hand is whether split-shift care is more appropriate. Live-in care aides are required to get a minimum of 5 hours of uninterrupted rest at night; if they are not able to, then split-shift care is more appropriate. The documentation provided demonstrates that the patient's personal care needs are continuous and unscheduled and are of such a frequency that precludes the required rest window for a live-in aide. Therefore, split-shift continuous care is medically necessary and appropriate for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic deletion syndrome, focal seizure disorder. 
Treatment: Personal Care Assistance Services. 

The insurer denied: Personal Care Assistance Services. 
The denial is upheld. 

The patient is a toddler male child with medical history significant for genetic deletion syndrome, focal seizure disorder, autism spectrum disorder, hypoglycemia, and global developmental delay. He is ambulatory but requires supervision. He is non-verbal, has difficulty focusing, has poor safety awareness but no self-injury. He is incontinent of bladder and bowel, approximately six diaper changes a day. He has no difficulty swallowing per mom but takes limited solid foods. The patient was most recently hospitalized for seizure associated with cyanosis. Prior to that the patient was hospitalized 8 months ago. The patient lives with his mother who is his primary and sole caregiver as well as his four-year-old brother. The patient's father does not live in the home and visits periodically. A nurse travels with the patient to and from school and remains at school with him to monitor for seizure activity and administer emergency medication for prolonged seizure. The patient is not allowed to be at school without a nurse. In school, the patient receives occupational therapy (OT) and physical therapy (PT) three times a week and speech therapy (ST) five times a week. Personal care needs include those typical of a child the patient's age such as meal preparation, assistance with meals, bathing, assistance with dressing, maintenance of safety, bowel and bladder care, and close monitoring due to lack of safety awareness. In addition, medical needs include maintenance of seizure precautions and medication administration. 

The proposed treatment is not medically necessary. 

This patient has disabilities as a result of and in addition to his genetic condition, seizures, and autism. He requires assistance typical of his age as described above, as well as maintenance of seizure precautions and medication administration. In a household with one parent and two children under the age of five years, there is a lot of work and both children require assistance with activities of daily living. However, based on the documentation submitted, a personal care assistant is not medically necessary at this time. The patient's care is custodial and can be safely managed by his primary caregiver. 

Note that over time, this child's needs may increase, and he may require assistance above and beyond what would be necessary for a child his age. If this occurs, it would be reasonable to revisit the need for personal care assistance. However, at this time and based on the documentation, a personal care assistant is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left hemiparesis, osteoarthritis and weakness

Treatment: an increase in Consumer Directed Personal Assistance (CDPAS) Services from 7 days per week, 7 hours per day; 49 hours per week to 7 days per week, 24 hours per day (continuous care by more than one person) 168 hours per week

The insurer denied coverage for an increase in Consumer Directed Personal Assistance (CDPAS) Services from 7 days per week, 7 hours per day; 49 hours per week to 7 days per week, 24 hours per day (continuous care by more than one person) 168 hours per week

The denial is overturned.


This is an elderly female with chronic medical problems including left hemiparesis, osteoarthritis and weakness.   She lives with her daughter and 3 grandchildren in a 4-bedroom apartment.  The patient's daughter and granddaughter are the paid caregivers.  The plan approved 49 CDPAS hours/week and the request is for Consumer Directed Personal Assistance (CDPAS) Services 7 days per week, 24 hours per day (continuous care by more than one person) 168 hours per week.

The patient's cognitive skills are described as moderately impaired.  She is reportedly totally dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient also reportedly requires maximal assistance for bathing, personal hygiene, dressing, eating, bed mobility and toilet transfer/use.  She is reportedly dependent for locomotion and non-ambulatory.  The patient's is reportedly frequently incontinent of bladder and bowel.  

The letters from the patient's treating physician, care logs, as well as letters her family were reviewed.  The patient's condition and functional deficits are at a level or unpredictable as to require the requested Consumer Directed Personal Assistance (CDPAS) Services 7 days per week, 24 hours per day (continuous care by more than one person) 168 hours per week.  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by Consumer Directed Personal Assistance (CDPAS) Services 7 days per week, 24 hours per day (continuous care by more than one person).  

From a physical medicine and rehabilitation perspective, the requested increase in Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day (continuous care by more than one person) 168 hours per week is medically necessary.  

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 an increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 7 hours per day; 49 hours per week to 7 days per week, 24 hours per day (continuous care by more than one person) 168 hours per week services is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional
Treatment: Pharmacy/Prescription Drugs

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes Mellitus Type 2
Treatment: Pharmacy/Prescription Drugs-Mounjaro
The health plan denied the prescription medication of Mounjaro as not meeting its formulary criteria. The reviewer has overturned in whole the health plan's determination.

This is a patient diagnosed with Type2 diabetes mellitus (DM). This request is for Mounjaro. As reported the patient has tried and failed Trulicity which she lost only 6 pounds (lbs.) She started Wegovy and since then she titrated doses and reported no weight changes or changes in appetite. As per a provider visit note she is on metformin and Wegovy. She has hyperlipidemia (HLD). Her average blood sugar levels over the past 3 months (A1C) improved to 6.6 % from 7.1ercent (%).

The formulary alternatives are not as effective as the requested non-formulary medication. I overturn in whole the health plan's determination.
The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a GLP-1 (glucagon-like peptide 1) and GIP (Gastric inhibitory polypeptide) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3).
The patient has failed the maximum dose of Semaglutide (the active ingredient in Ozempic and Wegovy) due to not reaching A1c goals and lack of weight loss. The surpass trial showed that Mounjaro is superior to Ozempic. The patient is reported to have failed Trulicity. Given the fact that the patient failed Ozempic due to the A1c not being at goal, the patient is not expected to succeed with the other formulary alternative Victoza. Therefore, the trial of mounjaro is appropriate. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Constipation
Treatment: Trulance
The health plan denied Trulance.
The determination is overturned.

The patient is a female with chronic idiopathic constipation. She has failed Linzess 72 micrograms (mcg), on which abdominal x-ray showed moderate stool retention, 145 mcg, and 290 mcg, as well as Amitiza 24 mcg. She has failed magnesium hydroxide, MiraLAX, and Dulcolax. She has had improvement with Trulance.

At issue is whether the formulary drugs, lubiprostone (generic Amitiza) and Linzess, will be or have been ineffective, would not be as effective as the non-formulary drug, Trulance, or would have adverse effects.

The health plan's determination is overturned in whole.

The request for Trulance is supported over the use of the formulary alternatives lubiprostone (generic Amitiza) and Linzess. Trulance is indicated and is Food and Drug Administration (FDA) approved for the treatment of constipation. [1] Trulance has a different mechanism of action than osmotic and stimulant laxatives (which the patient has attempted). [2] Guidelines for the treatment of constipation recommend the use of pharmaceutical laxatives (specifically Linzess and Trulance, with a 'strong' recommendation) as effective after failure of over-the-counter laxatives. [3] Multiple studies have found Trulance to be safe and effective for the treatment of multiple types of constipation. [4-6] Additionally, the patient has already attempted both Linzess and Amitiza; although the generic form of Amitiza has not been attempted, it would not be expected to be effective after Amitiza was ineffective. For these reasons, the request for Trulance is supported for the treatment of chronic idiopathic constipation in this case.