Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment is Gel-One 30MG (milligram) /3ML (milliliter) IX PRSY
The insurer denied coverage for Gel-One 30MG/3ML IX PRSY
The denial is upheld

This is the case of an adult female with history of osteoarthritis of the knees. X-rays of the knees showed severe degenerative joint disease. Per the office visit note, the patient's right knee had been injected with viscosupplementation # (number) 1 several weeks prior, and her pain had diminished. The left knee was injected. Per the office visit note, the patient's left knee was doing somewhat better, and she was presenting for viscosupplementation of the right knee. 

The scientific literature does not show difference in efficacy between formulary agent and Gel-One 30MG/3ML IX PRSY. There are no reports nor studies which recommend Gel-One 30MG/3ML IX PRSY. 
The facts are the patient received the medication without use of the formulary agent. There was no report of intolerance nor failure to improve with a formulary agent. 

The facts are additional injections are only prescribed if at least 6 months have passed with objective evidence of improvement. The provider has not followed the recommended guidelines for use. 

In conclusion, based upon use of a non-formulary agent and an insufficient time period between injections, there would be no indication for the Gel-One 30MG/3ML IX PRSY.

The formulary drug(s) will not be likely to cause the patient an adverse reaction.

Has the formulary drug(s) been ineffective based on the patient's clinical history? NO 

The requested drug will not be more effective than formulary drug. 

The insurer's denial of coverage for Formulary Exception for Gel-One 30MG/3ML IX PRSY is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Diabetes
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary.
The health plan's determination is overturned.

This is a female with a history of type I diabetes. She presented with one day of emesis and an inability to tolerate oral intake. She had 8 episodes of emesis. She is on an insulin pump. Her glucose sensor has been malfunctioning. The infusion site was changed the night before at 11 PM. Glucoses have been high since last night. The most recent at home was greater than 400. Urine was positive for ketones at home. The mother noticed that the infusion site did not look normal and so she administered long-acting insulin and short acting insulin via injection. She contacted endocrinology who referred her to the emergency department. Labs showed an anion gap of 10.8 with a glucose of 220 and 238 and a potential hydrogen (pH) of 7.26 with a partial pressure of carbon dioxide (PCO2) of 33.9, a potassium that was elevated at 5.3 and a magnesium that was low at 1.6, as well as the blood urea nitrogen (BUN) and creatinine that were elevated. In the emergency department, she received a normal saline bolus and was admitted for further management of the endocrinology service. The notes report that the patient was treated with subcutaneous insulin and intravenous (IV) fluids given the mild diabetic ketoacidosis. She was admitted for management of diabetic ketoacidosis and dehydration.
At issue is the medical necessity for the inpatient stay.

The health plan's determination is overturned, in whole.

Yes. Hospitalization for diabetic ketoacidosis is universally medically necessary[1-9]. Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require Intensive Care Unit (ICU) level care if severe, and acute inpatient admission if mild [1,3,4,5] until they have closed their anion gaps and are tolerating oral intake and are back on their home insulin regimen [10,11]. The patient was admitted for treatment of diabetic ketoacidosis. Mild diabetic ketoacidosis still requires frequent blood glucose monitoring and monitoring of electrolytes. The complexity of the frequent checks is consistent with an acute inpatient stay rather than an observation stay. Furthermore, the patient needed to have her pump malfunction troubleshooted and be restarted on their insulin pump. The requested stay is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The health plan's determination is upheld in whole.

The patient is a female who presented to the hospital with left sided shoulder pain and arm weakness. On the morning of presentation to the emergency room, the patient woke up around 4 AM. She noticed a pain in her shoulder and a heaviness in her arm. She presented to the hospital for further evaluation. She was admitted to the hospital. A computed tomography (CT) scan of the head showed no acute process. A computed tomography angiography (CTA) of the head and neck showed no hemodynamically significant stenosis or occlusion. A magnetic resonance imaging (MRI) of the brain was performed and negative for acute ischemia. The patient had a prior similar presentation with a negative work up. The patient was discharged home on her usual medication's. Thiamine was added for a suspected vitamin deficiency. She was instructed to follow up with outpatient neurology. 
The subject under review is the medical necessity for the inpatient stay.

The requested inpatient hospital admission was not medically necessary for this patient. The patient presented to the hospital with left arm pain and weakness. Typically, stroke and/or transient ischemic attack do not present with pain but with weakness or sensory changes. The patient had a prior admission for the same complaint. At that time, a workup was negative for acute ischemia. Nonetheless, the patient was admitted to the hospital and underwent another evaluation for Stroke. During this evaluation, she had an unremarkable CT scan of the head, CTA of the head and neck, and MRI of the brain. There was not an acute ischemic stroke. The patient was evaluated by neurology and outpatient follow-up was recommended.
An acute inpatient hospitalization was not medically necessary as there were no diagnoses that required hospitalization. The patient had arm pain and heaviness with no clear diagnostic explanation. The patient did not have a stroke. Due to the stereotyped nature of the event, this was also unlikely transient ischemic attack. All of the imaging was negative. The patient did not have any significant abnormalities of her vital signs or laboratory studies. The patient did not require complex nursing care or rehabilitation and an inpatient facility due to a significant neurologic deficit. The neurologic deficits rapidly improved and were non-disabling on presentation.
There were no significant changes made to the patient's medical treatment. She was continued on all of her outpatient medications.
The patient could have been managed at a lower level of care status.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied Intracept Procedure. 
The denial is overturn. 

The patient is a male who has lower back pain for more than 10 years. His pain is dull aching, shooting, and stabbing localized in the lower back without radiation. He reports that the pain is worse with prolonged sitting and standing and interfere with his ability to sleep at night. Pain level ranges from 3/10 to 10/10. He has tried pain medications and epidural injections without adequate relief. Physical exam (PE) revealed limited range of motion (ROM) of lumbar spine with diffused paraspinal tenderness. Lumbar spine magnetic resonance imaging (MRI) showed mild foraminal stenosis at lumbar (L)3-4, mild central canal stenosis at L4-5 and L5-sacral (S1), and Modic type 1 changes at L4 and L5.
The issue is whether Intracept procedure is likely to be more beneficial for this patient's condition than standard treatment. 

The proposed Intracept Procedure is likely to be more beneficial than standard treatments for this patient's condition.
The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient has persistent back pain consistent with Modic changes in L4 and L5 vertebrae. He is a candidate for Intracept procedure based on his symptoms, MRI findings and current clinical studies. He has severe pain for more than 10 years and failed extensive treatments. Further interventions are medically necessary to improve his pain and functionality. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs [NSAIDs], opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, Intracept procedure is likely to be more beneficial for this patient than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied Intracept Procedure. 
The denial is upheld. 

The patient is a male with chronic back pain. The patient has prior undergone lumbar injections. The patient is noted to have low back pain with radiation to bilateral buttocks. Lumbar injections resulted in some relief. Pain is rated 4 out of 10. He is currently on multiple medications. Physical exam demonstrated lumbar spine range of motion limited, sensory intact from lumbar (L)2-sacral (S)1. Magnetic resonance imaging (MRI) lumbar spine demonstrated L4-5 disc bulge with superimposed herniation, L3-4 facet arthropathy. The patient's diagnoses include chronic bilateral low back pain with bilateral sciatica, vertebral genic low back pain. There is a request for Intracept Procedure. This is under review to determine if it would be more beneficial for this patient than standard treatment.

The proposed health service or treatment Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's 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 Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied Intracept Procedure. 
The denial is upheld. 

The patient is a male. Records indicate the patient has a history of chronic low back pain. It was noted that the provider requested approval for the Intracept procedure for intraosseous ablation of the basivertebral nerves. 

In the letter of appeal the provider states that this procedure is an innovative procedure to address chronic low back pain identified by Modic changes and fulfills a treatment gap for patients with chronic back pain. The provider stays the patient's back pain began more than 10 years ago and he has had multiple treatments including medication management and transforaminal epidural steroid injections. Medications tried have included ibuprofen, meloxicam, oxycodone and Percocet. Pain has had a significant impact on activities of daily living and the pain is rated at 7/10. The provider states the patient had a magnetic resonance imaging (MRI) performed showing degenerative and plate changes at disc space lumbar (L) 4-L5 and therefore this is where the pain is coming from. The provider is requesting reconsideration of approval for this procedure. The subject under review is whether the Intracept procedure is likely to be more beneficial for this patient than any standard treatment for the patient's condition.

The proposed Intracept procedure is not likely to be more beneficial than standard treatment options for the patient's condition or disease. The patient is noted to have a history of chronic back pain that benefited with "significant improvement" from an epidural steroid injection. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, the MRI provided shows multiple other potential pain generators and no evidence of Modic changes according to the radiology impression. This procedure remains experimental and investigational as there is a lack of high quality studies evaluating the long-term risks and benefits of this 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 a lack of high-grade evidence and 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. This procedure is considered experimental and investigational and there is no evidence to suggest that this treatment would be more likely to result in benefit over that of standard treatment options.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 mg every 6 weeks
The insurer denied the Stelara 90 mg every 6 weeks.
The determination is overturned.

The patient has severe Crohn's disease and has previously tried and failed steroids and immunomodulators. He was started on Stelara and was initially doing well on Stelara at standard dosing every 8 weeks but lost response as manifested with a flare of his Crohn' disease. Therefore, the attending provider escalated the dose of Stelara to 90 milligrams (mg) every 6 weeks to treat his severe Crohn's disease. He continued to have symptoms of diarrhea around the sixth week following his Stelara injection. The attending gastroenterologist is requesting the continued use of Stelara 90 mg subcutaneous (SC) every 6 weeks to treat this patient's severe Crohn's disease. At issue is the medical necessity of the requested Stelara every 6 weeks as the patient has not tried and failed Humira (adalimumab) and Entyvio (vedolizumab).

Yes, requested health service/treatment of Stelara 90 MG is medically necessary for this patient.
This patient has been on Stelara and is responding to the medication albeit with an escalated dose. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize the dose of the biological agent before switching to another agent. Therefore, it is medically necessary to use Stelara 90mg SC every 6 weeks to treat this patient's severe Crohn's disease to prevent immunogenecity and hence loss of response to the medication. 
The only reasons to stop any biologic agent used for treatment of Crohn's disease are:
1)	an adverse reaction or
2)	a contraindication or
3)	loss of response to the medication.
If the patient fails Stelara at the maximum dose escalation of 90 mg SC every 4 weeks, then it would be appropriate to switch the patient to another biological agent with a different mechanism of action, either an anti TNF agent or an anti-integrin agent.

Since this patient was not responding to standard dosing of Stelara, it is reasonable for the dose of Stelara to 90 mg every 6 weeks.. Dose escalation in biologic therapy used in inflammatory bowel disease is well established in the medical literature and can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both.
Crohn's disease results from a pathological immune response to luminal antigens in genetically predisposed individuals. Since the causes of Crohn's disease are complex and only partially understood, treatment is based on the empiric use of anti-inflammatory drugs. Although multiple therapies for Crohn's disease currently exist, a substantial proportion of patients are unresponsive to conventional agents. Approximately a third of patients fail treatment with tumor necrosis factor (TNF) antagonists, and up to 40% of patients who initially benefit subsequently lose response.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history (PMH) of hypertension (HTN), diabetes mellitus type 2 (DM2), and myasthenia gravis (MG) and was admitted with complaints of (c/o) chest pain (CP) associated with shortness of breath (SOB) and coughing. Her vital signs were notable for tachycardia. The physical exam was notable for no apparent distress (NAD). Lab work was notable for a glucose of 388 and slightly positive troponin. A chest x-ray (CXR) showed no acute infiltrates. An electrocardiogram (EKG) showed no acute ischemic changes. The patient was diagnosed with hyperglycemia and chest pain and treated with insulin, anti-hypertensives, and clinical monitoring/observation. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care. 

No, the hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with c/o chest pain. An EKG did not demonstrate any acute ischemic changes. The patient's HEART [history, EKG, age, risk factors and troponin] score was 4 (moderately suspicious, less than [<] 45 years old and troponin 1-3 times (x) normal limit), indicating that the patient had a moderate score, and not a high score. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and cardiac biomarkers not high enough to indicate active acute coronary syndrome (ACS), no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

This is a case of a woman that was noted to be hypertensive following elective laparoscopic total hysterectomy with salpingo-oophorectomy.  Past medical history was significant for hypertension and obesity. The procedure was uncomplicated and post-operative blood pressure was 199/85 mm Hg (millimeters of mercury). The patient's pulse was 77 bpm (beats per minute), and no other abnormal findings were noted on physical examination. A 12-lead electrocardiogram revealed normal sinus rhythm without any ischemic abnormalities. The surgical team requested a medical consultation. Elevated blood pressure was deemed to be due to postoperative pain and recommendations were made for treatment with beta blocker, ACE (angiotensin-converting enzyme) inhibitor therapy as well as pain medication. The patient was observed in the hospital overnight and discharged the following day with a BP (blood pressure) of 146/64.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Hypertensive emergency is defined as BP>180/120 with target organ damage (Reference 1). This patient had no evidence of target organ damage and was deemed to be hypertensive in the setting of post operative pain.  Treatment goals for patients with hypertensive are to institute antihypertensive medications in an outpatient setting. AHA/ACC (American Heart Association/American College of Cardiology) guidelines for treatment of hypertension state that in patients with hypertensive urgency, outpatient therapy is recommended (Reference 1). Admission to the hospital for blood pressure management was not medically necessary (Reference 1,2.) In conclusion, this patient should have been managed at a lower level of care. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld. 

Per clinical documentation, this patient presented to the emergency department with right upper quadrant abdominal pain. A CT (computed tomography) scan demonstrated findings consistent with acute cholecystitis. Liver function tests were normal with the exception of mildly elevated AST (aspartate aminotransferase) of 76. White blood cell count was 7.95. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. There are no postoperative notes that indicates any further need for admission. Per MCG (Milliman Care Guidelines) criteria, laparoscopic cholecystectomy is considered an ambulatory procedure. Admission is indicated when there is conversion to an open procedure, severe infection postoperatively, care of active comorbidities, complications of the procedure, or a gallstone ileus. [7] There are no post-operative notes to indicate management of the patient or reason for inpatient admission. Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in this circumstance. Per provided clinical documentation, the inpatient admission was not medically necessary. 

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% (percent) increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. [9] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical necessity is not substantiated.