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

Diagnosis: History of stroke.
Treatment: Magnetic resonance angiography (MRA) with contrast.
The insurer denied MRA with contrast.
The determination is upheld.

This is a male patient with a history of a stroke with an occluded right vertebral artery who underwent embolectomy and stent placement. The provider has recommended brain magnetic resonance angiography (MRA) for surveillance of the left vertebral artery. No actual medical records were provided. At issue is the medical necessity of MRA with contrast.
There were no records outlining the patient's current status, neurological exam, past treatment, or recent imaging studies. This information was requested, and additional information was provided. While there were imaging studies provided, no records discuss the rationale for the procedure.  The patient is asymptomatic and the indications for the procedure are unclear.
Appeal type: Medical necessity
Decision: Overturned in Part


 Diagnosis: Failure to thrive

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

At time of admission the patient was an infant, female born at 39-week gestation by C-section with Apgar's 8 and 8 and a birth weight of 2.268 kilograms. She has a past medical history of congenital hip dysplasia, Prader-Willi syndrome, small for gestational age and feeding difficulties. After discharge she was readmitted for failure to thrive, hypotonia, hypoglycemia and bradycardia. During this admission she was noted clinically and by modified barium swallow to have uncoordinated suck and swallow and would fatigue during attempted oral feeds. After a prolonged admission she was transferred to another hospital for intensive feeding therapy. At the time she was taking most of her Gentlease 24 feeds by nasal gastric tube (NGT) boluses. 

The treating team is appealing for the full 16 days as the somatotropin delivery was delayed and there was a lack of nursing supervision to safely discharge. In addition, the team at the current hospital states that the earliest outpatient feeding appointment at the first hospital was late August. 

This patient has Prader-Willi syndrome, hypotonia and feeding issues. During her stay at current hospital her oral intake improved yet she still required nasogastric tube (NGT) feeds. By admission the mother had already demonstrated that she could both feed the child and could administer nasogastric tube (NGT) feeds. In addition, the child had demonstrated steady weight gain on the goal volumes of her feeds without vomiting, coughing, gagging or aspirating. 

Despite the benefits of growth hormone, it is not a critical medication that cannot be stopped for several days. Once the current hospital was aware that there was a hold on the medication it was rapidly resolved through discussions with the insurance coverage. Certainly, the need for growth hormone was not urgent to merit continued admission beyond the approved days. Likewise, since this child was already feeding safely with her mother there was no justification to remain an inpatient at current hospital waiting the first available outpatient feeding therapy appointment as stated in the appeal. 

This child had consistent documented weight gain and the mother was capable of continued feeds administration without skilled nursing present. This decision was rendered after review of the detailed of the current hospital's therapy notes, the details of the prolonged hospital admission at the previous hospital and the review of the management of Prader-Willi syndrome from UptoDate cited above.

Based on the above, the insurer's denial must be modified. 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 a continued stay rehabilitation admission is modified.  Inpatient admission is medically necessary for days 0 through 9 of admission; Inpatient admission is not medically necessary for days 10 through 16 of admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Difficulty ambulating/unsteadiness.
Treatment:  Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

This case involves a man with daily alcohol use who was admitted to the hospital with a complaint of unsteadiness. He has been experiencing difficulty with ambulation over several days. Evaluation showed a temperature of 98.8, pulse rate of 104, blood pressure of 165/115, and a body mass index (BMI) of 39.5. The patient is described as conscious, cooperative, and oriented x3, with normal cardiopulmonary exam. Abdomen was non-distended. Neurologically, there are no focal deficits. Laboratory studies reveal leukocytosis, with a white blood cell count of 16.1 normal hemoglobin. Electrolytes are stable; creatinine was 0.7. A chest x-ray did not reveal acute cardiopulmonary findings. The patient was admitted for declining functional status and cerebellar ataxia due to alcoholism. 

The inpatient hospital admission was not medically necessary. The patient was noted to have suffered a fall and had gait instability. He has documentation stating chronic alcohol abuse, causing cerebellar ataxia. Vital signs appeared fairly stable, with somewhat elevated blood pressure initially, but subsequently improved. Laboratory studies showed mild leukocytosis without evidence of an infection. The patient was assessed by a physical therapist, who recommended rehab services. The patient spent nearly two weeks in the hospital awaiting placement. Awaiting placement is not an indication of inpatient hospitalization. There is no documentation of severe alcohol withdrawal, severe electrolyte derangements, or persistent abnormalities of the vital signs. Acute medical needs are being actively addressed and cannot be managed in a lower level of care or what needs to be documented to qualify for inpatient status. As mentioned previously, the documentation of an inpatient diagnosis is lacking. The patient's symptoms can be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive heart failure.
Treatment:  Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift).
The insurer denied Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift).
The health plan's determination is overturned. 

This is a female patient with a history of congestive heart failure, atrial fibrillation, valvular heart disease, chronic hypoxic respiratory failure (on continuous supplemental oxygen), dementia, oropharyngeal dysphagia, hyperlipidemia, arthritis, and urinary incontinence. 

Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift) are medically necessary for this patient.
The recent Uniform Assessment System (UAS) shows that the patient's ability to perform activities of daily living (ADL) has decreased since the previous UAS. The patient is assessed at total dependence for dressing lower body and toilet use and extensive assistance for walking, locomotion, transfer toilet, and bed mobility. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time, and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of the medical necessity of increased PCA services. The patient does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This patient presented to the hospital complaining of chest pain.  The patient noted intermittent symptoms that worsened with deep inspiration. Pain was not exacerbated with exertion. Past medical history was significant for ischemic heart disease and coronary artery bypass graft (CABG), hypertension, diabetes mellitus, and substance abuse. On arrival to the hospital the patient was tachycardic with a pulse of 114 and blood pressure (BP) of 106/67.  The physical exam was significant for scattered wheezing on lung exam. 12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm without ST or T wave abnormalities. Serum blood testing demonstrated no elevation in high sensitivity troponin (13) and an elevated D-dimer. The patient was admitted to the hospital for further monitoring and treatment. The patient refused computed tomography (CT) chest with contrast to rule out pulmonary embolism. Dobutamine stress testing was non-diagnostic, as the patient could not reach target heart rate. Echocardiogram demonstrated moderately reduced left ventricular ejection fraction of 40% (percent).  The patient was treated with guideline directed medical therapy and discharged with cardiology follow-up. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain.  Physical examination was unremarkable and ECG failed to reveal specific findings consistent with an acute coronary syndrome. Serum blood testing did not reveal elevated troponin levels.  Risk assessment of patients presenting with chest pain and no significant ST changes on ECG as well as negative cardiac enzymes was performed by Poldevaart et al. (Reference 1).  Using the HEART (History, ECG, Age, Risk Factors, Troponin) score risk stratification schema, this patient would have an intermediate risk of future myocardial infarction or death within one year. Other investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (References 2&3). They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain that were managed in an observation unit had similar 30-day myocardial infarction rates as those admitted to the hospital (Reference 3). Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this 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: Medical necessity
Decision: Upheld

Diagnosis: Class II Occlusion
Treatment: Braces
The insurer denied braces.
The health plan's determination is upheld. 

The patient in question is a female with a Class II occlusion. She has 4 millimeter (mm) overjet and 5 mm overbite. The maxillary arch and mandibular arch have minor crowding. She is treatment planned for 24-30 months of orthodontics (braces) to correct her malocclusion.

Braces are not medically necessary.
The patient has minor crowding. Her bite is deep, but there is no indication of damage to the incisors or the palate in the photographs, and her cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage) on this patient.
There is no medical reason to correct her malocclusion with braces. The patient has a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 4 mm overjet but this amount of overjet does not affect oral health related quality of life. If her teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The determination is overturned.

This is a female patient with a past medical history (PMH) of lower back pain that has been ongoing for greater than 10 years. She has tried chiropractic, physical therapy and home exercises. She has had interventional therapies including facet injections, lumbar epidural steroid injection (ESI) and radiofrequency ablations. She has tried medications.  She rates her pain as a 7/10 on the Visual Analog Scale (VAS). Her pain impacts her sleep, chores, work and leisure activities. She had lumbosacral (LS) magnetic resonance imaging (MRI) which demonstrated Modic changes at thoracic (T) 11-12 and lumbar (L) 4-5. Her physical examination is notable for a mildly antalgic gait, positive facet loading, and tenderness to palpation of the lumbar paraspinal muscles. At issue is whether the proposed health service or treatment Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
It is possible that the proposed health service (thermal destruction of intraosseous basivertebral nerve [BVN]) at L4-L5 may be more beneficial than standard treatment. She has trialed standard treatments including physical therapy, chiropractic, standard first line injection therapy and medication management with ongoing significant pain. As outlined by Deer et al. (3), "based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals."
It is reasonable to consider the above procedure at L4-5 given that the patient has undergone standard therapy without durable benefit. She has demonstration of Modic changes on a recent MRI at L4-5 with difficulty with activities of daily living (ADLs) and daily work. It is reasonable to consider this procedure prior to considering more invasive options such as surgery (for which she had recent consultation). The above procedure may allow her to decrease use of oral narcotic and nonsteroidal anti-inflammatory drugs (NSAIDs) which carry their own risks.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The determination is upheld.

This is a female patient with complaints of low back pain. She had a magnetic resonance imaging (MRI) scan of the lumbar spine which shows slightly increased Modic type one and plate changes at lumbar (L) 4/5; evolution of previously noted Modic type I changes at thoracic (T) 11/T 12. The patient has complaints of chronic low back pain. The physical examination notes midline tenderness and left and right paraspinal musculature tenderness to palpation. Motor strength testing is normal. At issue is whether the requested procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease

The requested procedure is not considered more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to guidelines and cited references, despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. If approved despite non-recommendation, there should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between L3 and sacral (S) 1 on magnetic resonance imaging.
According to Becker, et.al: "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)."
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. As cited above, Becker. et.al trial indicated only a 17 patient observational study. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures.
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. In addition, no United States (U.S.) guidelines based on research recommend this treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The insurer denied Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The determination is upheld.

This is a female patient who was diagnosed with vertebrogenic low back pain. The patient was previously recommended to undergo intraosseous basivertebral nerve ablation procedure. The patient has tried multiple treatments including activity modification, chiropractic care, facet injections, ice, heat, home exercises, lumbar epidural steroid injections, medication management, physical therapy and radiofrequency ablation. Medications have included acetaminophen, celecoxib, hydrocodone, ibuprofen, lidocaine patches, meloxicam, and tramadol. The pain is rated at 8/10 and impacts activities of daily living. The provider noted the patient had magnetic resonance imaging (MRI) performed demonstrating Modic type I changes at disk spaces lumbar (L) 4- L5 and believes this is where the patient's chronic back pain is coming from. The provider requests that the previous denials be overturned.
An MRI of the lumbar spine showed slightly increased Modic type I endplate changes at L4 - L5; evolution of previously noted Modic type I endplate changes at thoracic (T) 11-T 12 to Modic type I and type II changes; otherwise, no interval changes.
The patient was seen regarding chronic low back pain. On the exam, there was midline tenderness at the bilateral paraspinal musculature with palpation, positive facet loading bilaterally. Straight leg raise testing was equivocal bilaterally. There was grossly limited lumbar range of motion with pain. Lower extremity motor strength was 5/5, reflexes were normal. The patient was recommended to undergo the Intracept procedure and this is under review.
The proposed health service or treatment intraosseous basivertebral nerve ablation (BVN) (Intracept Procedure) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient is noted to have complaints of chronic back pain that has not responded to conservative treatment and injections and MRI showed Modic changes at L4 - L5 which the provider believes is causing the patient's chronic back pain. However, 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 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 in 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.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is overturned.

This is a female patient being prescribed Wegovy for the treatment of obesity.  The prescribing physician provided a letter of support for this appeal. The letter states that the patient has obesity and hyperlipidemia. She started Ozempic with good results and was subsequently switched to Wegovy. Her current body mass index (BMI) is 30.7. She has lost more than 5 percent (%) of her baseline body weight on the medication and has been able to maintain the weight loss. The physician notes that the patient meets criteria based on a body mass index (BMI) of greater than 30 and she also has one or more weight-related comorbidities. She has been following lifestyle modifications while on the medication. She was previously approved for the 1.7 milligrams (mg) weekly dose, and the request is for approval of the 2.4 mg dose.
The health plan denied coverage for the requested medication because it is not on the plan formulary and does not meet their requirements for a covered benefit. They were unable to provide any formulary alternatives for the patient. At issue is whether the non-formulary drug being denied is clinically appropriate for the patient's condition.
The requested medication, Wegovy, is Food and Drug Administration (FDA) approved for the treatment of obesity. It has demonstrated efficacy in promoting weight loss in individuals who are overweight or obese. The recommended dose is to titrate up to 2.4 mg per week, which is the dosage formulation under review. This medication is clinically appropriate for the patient's condition and is being prescribed at a dose that is consistent with that which was previously studied in randomized clinical trials.