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

Diagnosis: Low Back Pain
Treatment: 64628 - Intraosseous Basivertebral Ablation (Intracept)
The insurer denied 64628 - Intraosseous Basivertebral Ablation (Intracept).
The denial is upheld.

The patient is an adult female with low back pain. She has tried physical therapy and multiple injections, including ESIs (epidural steroid injections), facet injections, RFA (radiofrequency ablation), and trigger point injections without benefit. MRI (magnetic resonance imaging) of the lumbar spine shows L (lumbar) 4-5 left foraminal narrowing, L5-S (sacral) 1 right foraminal narrowing, and L1-2 disc space degeneration with progressive marrow change.

The request for Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested Intracept procedure.

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 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 requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: 64628 - Intraosseous Basivertebral Ablation (Intracept)
The insurer denied 64628 - Intraosseous Basivertebral Ablation (Intracept).
The denial is upheld.

The patient is an adult female. Per the appeal letter, the patient has a history of pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes that are Modic in nature. The patient had pain for greater than six months until undergoing treatment for greater than six months. The appeal letter further notes that the patient's treatment included back surgery, facet injections, laminectomy, epidural steroid injections, medial branch blocks, physical therapy, radiofrequency ablation and trigger point injections. The patient's pain is noted to average 4/10. The appeal letter notes that MRI (magnetic resonance imaging) demonstrated Modic type changes at disc space L (lumbar) 4-L5.

The health plan should not cover the Intracept procedure.

Although the patient has a history of continued back pain and had tried prior conservative treatments, there were no sufficiently recent clinical documentation to support the requested procedure. Additionally, the imaging reports did not support findings of Modic type changes. Given that there was no supported documentation of any Modic type changes on MRI positive findings noted on exam from recent clinical documentation, it is not recommended at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Physical debility, hyperglycemia, hypertension, hyperlipidemia, joint pain, osteoporosis, and urge incontinence
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) Services to 10 hours/day, 7 days/week, for a total of 70 hours/week
The insurer denied an increase in CDPAP services to 10 hours/day, 7 days/week, for a total of 70 hours/week.
The denial is overturned.

This elderly female has conditions including physical debility, hyperglycemia, hypertension, hyperlipidemia, joint pain, osteoporosis, and urge incontinence. She is appealing the denial of an increase in consumer directed personal assistance program (CDPAP) services to 10 hours/day, 7 days/week, for a total of 70 hours/week. The health plan approved 42 hours/week. The Uniform Assessment System (UAS) evaluation completed 6 months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances, bathing, dressing, walking, locomotion, toilet transfer and bed mobility; limited assistance with managing medications and personal hygiene; and independent with eating. The patient has occasional bladder incontinence. Compared to UAS evaluation completed 2 years ago, there has been a decline with upper body dressing, toilet transfer, walking, locomotion, and bed mobility. A statement from her provider notes the patient is wheelchair dependent and bed ridden. She needs continuous care.

The proposed treatment is medically necessary. 

This patient has multiple chronic conditions. She is appealing the denial of an increase in CDPAP services to 10 hours/day, 7 days/week, for a total of 70 hours/week. The health plan approved 42 hours/week. UAS evaluation completed 6 months ago showed the patient requires assistance with all activities of daily living (ADLs), except eating. She is incontinent of bladder. Compared to UAS evaluation completed 2 years ago, there has been a decline with upper body dressing, toilet transfer, walking, locomotion, and bed mobility. The appeal statement notes the patient is wheelchair dependent and bed ridden. The information provided shows that this patient has significant limitations in functioning. This patient's needs for assistance have increased between UAS evaluations. The approved CDPAP services of 42 hours/week is insufficient to meet the patient's needs for assistance with all ADLs, except eating. The proposed increase to 70 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis.

Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is upheld. 

This case involves an adult male who was seen in the emergency department with a history of multiple sclerosis (MS) reporting worsening weakness in the left leg.  His blood pressure was 147/97 with a heart rate of 81. His temperature was 98.1 degrees F (Fahrenheit) with a pulse oximetry of 98% on room air.  He arrived in a wheelchair claiming to have a 1-week history of left foot drop. He was advised to come in for evaluation. Exam findings show limited left foot dorsiflexion and plantarflexion with the remainder of his examination unremarkable. There was low suspicion for a MS flare at that point with likely peripheral neuropathy.  Recommendation was for Magnetic Resonance Imaging (MRI) of the lumbar spine along with Physical and Occupational Therapy evaluation. The patient was subsequently admitted for lab work and consultation with neurology.

According to the Milliman Care Guidelines, the patient did not meet the criteria for inpatient admission. He had no related symptoms affecting cognition, no indication that the lower leg weakness was significantly progressive or severe and causing a concern for the patient's safety or significant functional disability.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic heart disease.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is a case of an adult patient with a history of ischemic heart disease, hypertension, and diabetes that presented to the hospital for cardiac catheterization following a positive stress test. The patient's left ventricle (LV) ejection fraction was 60%. Cardiac catheterization revealed in stent restenosis of the left anterior descending (LAD) artery and a mid-right coronary artery stenosis. A drug eluting stent was placed in the right coronary artery (RCA). No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization. The patient underwent an uncomplicated procedure, and a stent was placed in the mid right coronary artery. The patient was discharged the following day. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. In conclusion an inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

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 admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Neurogenic bladder
Treatment: Gemtesa 75 milligram (mg) tablet
The insurer denied coverage for Gemtesa 75 mg tablet.
The denial is upheld.

The patient is an adult male with history of erectile dysfunction (ED), benign prostatic hypertrophy (BPH), urinary urgency. The patient presented to Urologist for consultation regarding ED, urinary urgency. ED is well managed with tadalafil. Neurogenic bladder/ overactive bladder (OAB) is well controlled on solifenacin 5mg oral daily. The patient has a family history of dementia, and per the physician, it is not safe for the patient to continue this medication. The physician advised the patient to consider switching to Mybetriq or/and gemtesa. The insurer has denied coverage for gemtesa tabs 75mg once daily. They stated that there is no documentation that the patient has had serious side effects or drug failure with all of the formulary alternatives within the drug class. These drugs include oxybutynin, oxybutynin extended-release (ER), tolterodine immediate-release (IR) or ER, trospium (ER), solifenacin, darifenacin and myrbetriq. The appeal by the physician is noted and read in detail. The patient has family history of dementia, but the patient himself has no history of dementia.

The formulary drugs are not likely to cause the patient an adverse reaction -of course, every prescription formulary or not, has potential to cause side effects.

The formulary drugs have not been ineffective based on the patient's clinical history from the submitted documentation.

The requested drug likely would not be more effective than the formulary drug, it is a different class of medications: gemtesa/mybetriq are beta agonist medications; the others are anticholinergic medications.

If a concern exists based on family history of dementia, one could also prescribe mybetriq which is not anticholinergic and is considered a formulary alternative to gemtesa. This patient does not have dementia as a personal diagnosis, as per the medical records.

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 denial of the request for Formulary Exception for Gemtesa 75 mg tablet is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive Emergency
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This a case of an adult patient that presented to the hospital with complaints of headache and chest pain. Past medical history was significant for hypertension, diabetes mellitus, stroke, hepatitis C virus, and polysubstance abuse. On arrival to the hospital the blood pressure (BP) was elevated: 220/110 and the pulse was 84. Physical exam revealed bilateral pedal edema. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with left ventricular hypertrophy (LVH) and possible old septal myocardial infarction and no ST (interval on EKG) or T (interval on EKG) wave abnormalities. Serum blood testing revealed an elevated troponin 0.041 nanograms per milliliter (ng/ml) and elevated B type natriuretic peptide (BNP) 801 picograms (pg). The patient was admitted to the hospital for treatment. Computer tomography (CT) scan of the head revealed no intracranial abnormality and CT scan of the chest revealed no evidence of aortic dissection. The patient was treated with antihypertensive agents and discharged home following work up.

Hypertensive emergency is defined as BP>(greater than) 180/120 with target organ damage. (Reference 1) This patient presented with a systolic BP of 220. The Troponin and BNP levels were elevated consistent with left ventricular target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Admission to the hospital for aggressive blood pressure management was necessary in this case. The American Heart Association guidelines recommend admission to the intensive care unit (ICU) for management of hypertensive emergencies. (Reference 1) 

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 the inpatient admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara every 4 weeks
The insurer denied: Stelara every 4 weeks
The denial is: Overturned

The patient is a female with Crohn's disease, history of small bowel obstruction, and history of melanoma, uterine cancer status post hysterectomy, breast cancer status post lumpectomy and chemoradiation, and family history of colorectal cancer in her brother and her father. She previously failed infliximab due to melanoma. She was started on Stelara, with ongoing symptoms. Colonoscopy showed residual ulcerated ileal stricture with possible fistula; biopsies showed quiescent ileitis. She presented with 4-5 liquids bowel movements per day (including nocturnal bowel movements) and abdominal cramping. She presented with 6-7 watery, urgent bowel movements per day. The coverage is requested for Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.
Current medical literature supports the dose escalation of Stelara to 90 mg every 4 weeks as likely to be more beneficial than any standard treatment or treatments for the patient's Crohn's disease in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al.). Another study showed a 73% response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al.). The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor medications, which the patient has failed (Tuskey, et al). A study showed dosing at 90 mg every 4 weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every 4 weeks (Kopylov, et al.).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara every 4 weeks
The insurer denied: Stelara every 4 weeks
The denial is: Overturned

The patient is a female who has severe ileocolonic Crohn's disease. She has previously tried and failed steroids, and an anti-tumor necrosis factor (TNF) agent (infliximab). She was started on Stelara in 2022 and did well initially on Stelara at standard dosing every 8 weeks but recently lost response. She had evidence of active stricture on colonoscopy. Hence the attending gastroenterologist is requesting the use of Stelara at the escalated dose of 90 milligrams (mg) subcutaneously (SC) every 4 weeks to treat this patient's severe Crohn's disease.

the proposed health service or treatment Stelara (every 4 weeks) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90mg every 4 weeks. Dose escalation in biologic therapy used in inflammatory bowel disease 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. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the biological agent before switching to another agent. Therefore, it is appropriate to use Stelara 90mg SC every 4 weeks to treat this patient's severe Crohn's disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara every 4 weeks
The insurer denied: Stelara every 4 weeks
The denial is: Overturned

The patient is a female with a diagnosis of Crohn's disease. The patient has a history of (H/O) stricturing ileal disease and was formerly on infliximab which was stopped after a diagnosis of melanoma. The patient was placed on ustekinumab 90 milligrams (mg) every (Q) 8 weeks. Despite this treatment the patient still has diarrhea and obstructive symptoms possibly consistent with a small bowel obstruction (SBO). A recent colonoscopy demonstrated a residual ileal ulcerated stricture and possible sinus tract formation although generally the mucosa is healed compared to prior to therapy. The patient has required courses of steroids for active disease flares.
Because of only marginal improvement on Stelara 90 mg Q 8 weeks the provider has requested dose escalation to Q 4 weeks. This request is considered experimental/investigational and therefore not medically necessary.
Patients with Crohn's disease treated with ustekinumab who experience inadequate response, or loss of response after standard induction and/or maintenance dosing may benefit from dose escalation to Q 4 weeks. In a large, multi-national study, 142 patients were included. The patients were dose-escalated to ustekinumab 90 mg Q 4 weeks after a median treatment duration of 30 weeks. At week 16 from escalation to Q 4 weeks, 73/142 (51.4%) responded to treatment, including 55/142 (38.7%) in clinical remission. Corticosteroid-free remission was achieved in 6/34 (17.6%) patients on corticosteroids at the time of escalation; 118/142 (83%) continued treatment beyond week 16. Follow-up data beyond week 16 were available for 74/118 (62.7%) patients. On the last follow-up, 51/98 (52%) patients with available data responded to treatment, including 41/98 (42%) in clinical remission. Furthermore, in a recent meta-analysis, 55% of patients (95% confidence interval, 52%-58%) with inadequate response or loss of response who underwent ustekinumab dose escalation to Q 4 weeks achieved clinical response. Approximately 61% of patients were able to achieve endoscopic response, including 29% who achieved endoscopic remission. Dose interval shortening to 4 weeks recaptured response in 57% patients.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention-deficit/hyperactivity disorder

Treatment: Vyvanse (lisdexamfetamine) 

The insurer denied coverage for Vyvanse (lisdexamfetamine) 

The denial is overturned.

This adult patient has Attention-deficit/hyperactivity disorder (ADHD) symptoms including difficulty paying attention, distractibility, difficulty listening, difficulty making transitions, disorganization, random outbursts of humming or singing, cannot take notes, misplaces things, lacks motivation, and is impatient. The patient has a diagnosis of ADHD-Inattentive presentation. The patient also has a diagnosis of Unspecified Anxiety Disorder. The patient reportedly tried Metadate, Methylphenidate, and Adderall in the past. The patient was also taking Fluoxetine. The request is for Vyvanse to target ADHD symptoms.
  
The insurer denied coverage for Vyvanse for this patient stating that prior authorization criteria for their plan was not met. They stated that the patient did not try all the preferred formulary medications for ADHD including Adderall Extended-Release (XR), Concerta, Ritalin Long Acting (LA), Metadate Controlled Delivery (CD), or Focalin XR.
  
This reviewer disagrees with the decision to deny coverage for Vyvanse for this patient as the medical records support that this was considered a medically necessary treatment. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are considered first line of treatment for ADHD. This patient has a diagnosis of ADHD and Vyvanse is considered a Food and Drug Administration (FDA) approved medication for ADHD. Vyvanse (Lisdexamfetamine dimesylate) is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. This has a different mechanism than the other mentioned psychostimulants. This medication gets activated after ingestion as it is a prodrug, abuse potential is considered less than other psychostimulants. This patient reportedly tried and failed the two main types of psychostimulants including 2 methylphenidate products in Metadate and Methylphenidate which were both formulary preferred medications for this insurer. In addition, the patient also took Adderall which is a dextroamphetamine/amphetamine product; Adderall XR is a formulary preferred medication. It was not as likely that another methylphenidate product or dextroamphetamine/amphetamine product would be more beneficial than trying Vyvanse which is different than these medication classes and FDA approved for ADHD. Vyvanse is considered a medically necessary treatment for this patient's ADHD. 

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 Vyvanse (lisdexamfetamine) is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Saxenda. 

The health plan denied the requested medication Saxenda, as not medically necessary. The health plan's determination is overturned. 

This is a female diagnosed with obesity. This request is for Saxenda. As reported, she started on Saxenda. She has lost 5 % of her body weight since starting. She is currently on Saxenda 3 milligrams (mg) daily. The provider states she has had an inadequate response to Phentermine, Orlistat and Trulicity. 
Her body mass index (BMI) was 40.56. 
At issue is whether the formulary drug (Trulicity, Ozempic, Victoza) will be or has been ineffective, would not be as effective as the non-formulary drug (Saxenda), or would have adverse effects. 

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

The formulary drugs have not been shown to be effective for the treatment of obesity, as there are no studies using the formulary drugs for obesity.