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

Diagnosis: Uterine fibroids
Treatment: procedure code 0404T x 1 Radiofrequency Ablation of Uterine Fibroids
The insurer denied coverage for procedure code 0404T x 1 Radiofrequency Ablation of Uterine Fibroids
The denial is overturned

Based upon review of these medical records, and the medical literature, it is my expert medical opinion to overturn this denial of coverage for outpatient procedure 0404T X 1. This procedure is indicated for women suffering from symptomatic submucosal fibroids who experience excess blood loss with other common symptoms. There is scientific evidence in peer-reviewed literature to support a result of improvement in health outcomes. The outpatient procedure 0404T x 1 has had final approval by the Food and Drug Administration (FDA) for ablation of fibroids. This patient is a good candidate for outpatient procedure 0404T x 1. This Sonata outpatient procedure 0404T x 1 is an effective, available treatment for this patient at this time, since there are several effective treatments, whether one is the best or not for a particular patient would not only depend upon their pathology and symptoms, but also their preference to undergo less invasive surgery, as in this case. The adverse risks are not increased over standard treatment/services. This requested service is likely to be more beneficial for this patient than other standard treatments/procedures.  

In summary, the denial of the outpatient procedure 0404T x 1 and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphoma
Treatment: Home Health Care (HHC) - Level 2 Personal Care Services (PCS), per 15 minutes increase to 84 hours/week 
The insurer denied the HHC - Level 2 PCS, per 15 minutes increase to 84 hours/week.
The denial is upheld.

The patient is a female with medical history notable for Mantle Cell lymphoma, type 2 diabetes mellitus, arthritis, and urinary incontinence. The patient is approved for 42 hours/week of level 2 personal care services (PCS). The patient and her care team requested an increase to 84 hours/week, and this request was denied by the health plan. This denial is the subject under review.

The most recent office visit note from the treating oncologist was provided for review. The notes state that the patient "became very weak and fell 2 weeks ago." She was seen at the hospital and had workup including lumbar puncture (LP) with no suspicion of lymphoma relapse. She currently resides at a rehabilitation facility. The physician states that she "needs full assistance at home due to severe weakness. Needs assistance at home with bathing, cooking, feeding, giving medications. Needs assistance with ambulation, patient is high risk of fall."

A Uniform Assessment System (UAS) was completed and was available for review. The patient was noted to have modified independence with cognition with some forgetfulness. From a functional standpoint, she requires maximal assistance for meal preparation, housework, and shopping. She requires extensive assistance for managing finances, managing medications, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing, toilet use, and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, and toilet transfer. She is independent with bed mobility and eating. Joint pain and dizziness impact her ability to complete tasks. She is frequently incontinent of urine and uses liners as needed. She is continent of stool. Compared with a prior UAS, she declined in the following functional domains: toilet use, dressing lower body, and hygiene. A task tool associated with the most recent assessment recommended 37.25 hours/week to address her functional needs, an increase from 27.33 on the prior assessment.

The health plan's determination is upheld.

The requested Home Health Care (HHC) - Level 2 PCS, per 15 minutes increase to 84 hours/week has not been demonstrated to be medically necessary for this patient.

The patient had a UAS performed following her fall, which was about a month after her prior assessment. It did demonstrate increased functional needs, and the task tool recommended an additional ten hours for a total of 37 per week. The patient is approved for 42 hours/week. There is no documentation to support unmet personal care needs while receiving 42 hours/week. In the absence of data to suggest unmet needs, it is reasonable to use the task tool as a guideline to determine an appropriate number of hours to meet her personal care needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cystinuria.
Treatment:  Thiola EC tablets (Thiola EC).
The insurer denied the request for Thiola EC.  
The health plan's determination is upheld.

The patient is a female with recurrent nephrolithiasis secondary to cystinuria. Her stone burden is large with a developing staghorn calculi despite prescribing appropriate therapy with alkalinization of the urine, but suboptimal fluid target goals. Her most recent note reports a urine potential hydrogen (pH) of 8, consistent with successful alkalinization with Potassium Citrate. With an ongoing, symptomatic stone burden the pediatric nephrologist is requesting approval for Thiola EC. Insurance has denied this, stating that D-penicillamine has not been used, and this is the preferred agent for treatment of cystinuria.

The health plan in its determination of medical necessity has acted reasonably, with sound medical judgment and in the best interest of the patient. They are providing coverage for a Food and Drug Administration (FDA) approved chelation therapy for cystinuria.

Thiola EC is not medically necessary for the patient. Although Thiola EC is commonly used as the first line of therapy in the United States for the treatment of recurrent kidney stones in cystinuria, D-penicillamine is also approved therapy and is considered, in limited studies, equally efficacious. Historically, Thiola EC was considered to be a safer therapy alternative to D-penicillamine, but this is less clear. If the patient were to have a severe, adverse reaction to D-penicillamine Thiola EC would then be medically necessary given the patient's severe disease and negative impact that the stone burden has had on the patient's kidney function.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other/Dental Issues
Treatment: Dental/Orthodontic Procedure/Periodontal Scaling & Root Planning on the upper left and lower left quadrants
The health plan denied the requested Periodontal Scaling & Root Planning on the upper left and lower left quadrants as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who presented for the treatment of scaling and root planning on the upper left and lower left areas of the mouth. Provided for review are radiographic images, clinical periodontal indices, health plan language, and letters of appeal and denial.

In question is the medical necessity for the treatment of periodontal scaling and root planning on the upper left and lower left areas of the mouth.

I uphold in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of periodontal scaling and root planning on the upper left and lower left is not medically necessary for this patient.

Health plan language states that in order for the treatment to be approved, the reviewer must see that there is moderate to severe problems with the gums and bone surrounding the teeth with hardened plaque on the teeth, large spaces between the teeth, or issues with the surrounding bone defined as periodontal pocketing with bone loss causing mobility, root exposure and/or infection. The utilization of scaling and root planning as a periodontal therapy requires that the patient have evidence of attachment loss, based on the provided documentation there is not attachment loss. The mere presence of deep probing depths does not indicate that the patient has any attachment loss as periodontal pocketing also occurs due to anatomical variation and is considered to be a psuedopocket. The therapy of scaling and root planning in a patient without periodontal attachment loss has been shown to damage the periodontal attachment and result in attachment loss.

From the provided documentation there is not a diagnosis of periodontal disease nor evidence of periodontal disease in the patient. Hence, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis 
Treatment: Taltz
The insurer denied coverage for Taltz.
The denial is upheld.

The patient is an adult male with psoriasis and psoriatic arthritis. The patient has failed topical therapy and methylprednisolone. The health plan has multiple available biologic options, including Humira, Stelara, Tremfya, Cimzia, Skyrizi, and Cosentyx. The request is a formulary exception for Taltz.

Based on the medical documentation, Taltz is not medically necessary. There is no documentation of a contraindication nor a specific Taltz specific indication which would reasonably favor the use of Taltz over multiple formulary alternatives. Taltz and Cosentyx are both within the Interleukin (IL)-17 inhibitor class and would reasonably be expected to have similar efficacy and safety. Without blinded, controlled studies evaluating the safety and efficacy of Cosentyx with Taltz it is reasonable to assume that both medications have a similar safety and efficacy profile given their similar mechanism. There is no documentation provided which would warrant the use of Taltz over formulary alternatives, including Cosentyx. The use of Taltz would not be medically necessary over approved formulary alternatives in a patient who has not tried any prior biologic and with no contraindication to available reasonable alternatives. The denial is upheld based on the documentation provided.  

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

Diagnosis: Alzheimer's disease, spinal stenosis, colon cancer, mood disorder sciatica, and bilateral knee osteoarthritis
Treatment: Consumer Directed Personal Assistance Program (CDPAP) 6 hours per day, 7 days per week, totaling 42 hours per week
The insurer denied coverage for CDPAP 6 hours per day, 7 days per week, totaling 42 hours per week.
The denial is upheld.

This is a patient with a medical history of spinal stenosis, sciatica, and knee osteoarthritis. The patient's physician states that the patient is a candidate for knee replacement surgery. The patient lives alone in a private residence. The insurer approved CDPAP 4 hours per day, 7 days per week, totaling 28 hours per week. The patient is requesting CDPAP 6 hours per day, 7 days per week, totaling 42 hours per week, which is currently under review.

The Uniform Assessment System (UAS) was done on the patient. The patient's cognition is described as modified independent. The patient requires only limited assistance for bathing, lower body dressing and toilet transfer and use. The patient is frequently incontinent of bladder and continent of bowel. The patient is otherwise independent for personal hygiene, upper body dressing, eating and bed mobility. Supervision is needed for locomotion and ambulation. According to the treating physician's office visit note, the patient was able to ambulate with an assisted device. The patient's clinical condition and functional deficits are not at a level that require the requested CDPAP 40 hours per week. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved CDPAP services of 28 hours per week.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. From a physical medicine and rehabilitation perspective, the requested increase in CDPAP services for a total amount of 42 hours per week is not medically necessary.

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 increase in CDPAP services for a total amount of 42 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic pain 
Treatment: Hysterectomy
The insurer denied coverage for the hysterectomy.
The denial is overturned.

The patient is an adult with a complaint of chronic pelvic pain since a tubal ligation. The patient is also complaining of severe dysmenorrhea. The patient was placed on Micronor without any improvement. The patient and provider are requesting coverage for a hysterectomy. 

An ultrasound was performed. Findings were compatible with adenomyosis and a possible endometrial polyp. 

The preoperative diagnosis of adenomyosis is suggested by characteristic clinical manifestations (heavy menstrual bleeding and dysmenorrhea with a uniformly enlarged uterus), and a clinical diagnosis can be made with a transvaginal ultrasound or magnetic resonance imaging findings.

This patient, based on history and ultrasound findings has a diagnosis of adenomyosis.
As per the standard of care, for patients with bothersome symptoms who have completed childbearing, a hysterectomy is the treatment of choice. Gonadotropin-releasing hormone (GnRH) agonist treatment is a temporary solution. The patient has at least 10 years until reaching menopause and cannot be placed on a GnRH agonist for this duration. Hormonal treatment is reserved for patients who are interested in preserving fertility which is not the case for this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for the requested hysterectomy is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus 
Treatment: Mounjaro
The insurer denied the Mounjaro.
The determination is overturned.

This patient has a medical history of type 2 diabetes mellitus (DM) with polyneuropathy. Request for Mounjaro is under review. The patient has tried Trulicity, Januvia, and glimepiride. They switched from Trulicity to Mounjaro 8 months ago and their hemoglobin A1C improved from 9.8% (percent) to 7.1%. At issue is the medical necessity of the non-formulary medication, Mounjaro for the treatment of type 2 DM.

The patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. The patient has tried and failed Trulicity.

Studies have shown Mounjaro to be superior to Ozempic [1]. The mean change from baseline in the glycated hemoglobin level was 2.01 percentage points, 2.24 percentage points, and 2.30 percentage points with 5 milligrams (mg), 10 mg, and 15 mg of Mounjaro, respectively, and 1.86 percentage points with Ozempic; the estimated differences between the 5 mg, 10 mg, and 15 mg Mounjaro groups and the Ozempic group were 0.15 percentage points (95% confidence interval [CI], 0.28 to 0.03; probability (P) = 0.02), 0.39 percentage points (95% CI, 0.51 to 0.26; P < [less than] 0.001), and 0.45 percentage points (95% CI, 0.57 to 0.32; P < 0.001), respectively.

Rybelsus and Victoza are inferior to Ozempic, and Ozempic is inferior to Mounjaro. Given this patient has already tried and failed Trulicity, which is in the same drug class as the formulary alternatives and has very similar potency to lower hemoglobin A1C, they can reasonably be expected to fail the remaining formulary alternatives that they have not tried (Ozempic, Rybelsus, and Victoza).

The patient previously had a very high hemoglobin A1C and is now stable on Mounjaro. Without Mounjaro, this patient will be at increased risk of complications related to hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Axial Lower Back Pain and Intervertebral Disc 
Degeneration
Treatment: Via Disc Procedure (percutaneous injection of 
allogeneic cellular and/or tissue-based product intervertebral disc unilateral bilateral injection with fluoroscopic guidance code 0627T)
The insurer denied: Via Disc Procedure (percutaneous injection of allogeneic cellular and/or tissue-based product intervertebral disc unilateral bilateral injection with fluoroscopic guidance code 0627T)
The denial is upheld.

The patient is an adult female with axial low back pain. She tried a bilateral lumbar radiofrequency without benefit despite positive response to two bilateral L(lumbar) 4-S(sacral) 1 medial branch blocks. Her pain is rated at 8/10. The patient has tried physical therapy, gabapentin, and tramadol. X-ray of the lumbar spine shows progression of discogenic disease of the lower thoracic and lumbar spine with moderate L4-5 disc space loss at L4-5 and grade 1 anterolisthesis without instability. MRI (magnetic resonance imaging) of the lumbar spine shows L4-5 moderate right neural foraminal narrowing, which is predominately secondary to facet joint hypertrophy, at L5-S1 there is a predominately central disc protrusion without stenosis. The request for an intradiscal allograft at L4 and L5 with a Vivex Via disc was denied coverage by the health plan as investigational. The denial is being appealed.

The health plan should not cover the Via disc procedure.

Review of literature shows possible demonstration of safety indicating that viable disc tissue allograft may be a beneficial nonsurgical treatment for patients who have chronically painful lumbar degenerative discs. However, further studies would need to be performed to confirm efficacy. 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 at this time use of intradiscal injection using an allogenic cellular or tissue-based product to replace or supplement the disc tissue has not been medically proven to be effective and, therefore, is considered investigational. As such the health plan should not cover the requested health service.
The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease. Other treatment options may include other non-opioid medications (i.e., NSAIDs [nonsteroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., retrial physical therapy, home exercise program, chiropractor treatments) interventions (i.e., repeat medial branch blocks/radiofrequency ablation) and/or surgical interventions.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Axial Lower Back Pain and Intervertebral Disc 
Degeneration
Treatment: Via Disc Procedure (percutaneous injection of 
allogeneic cellular and/or tissue-based product intervertebral disc unilateral bilateral injection with fluoroscopic guidance code 0627T)
The insurer denied: Via Disc Procedure (percutaneous injection of allogeneic cellular and/or tissue-based product intervertebral disc unilateral bilateral injection with fluoroscopic guidance code 0627T)
The denial is upheld.

The patient is an adult female with axial low back pain. She underwent multiple procedures including radio frequency ablation. She has tried various medications as well as conservative treatment. Intra-discal allograft injections (VIA DISC NP [nucleus pulposus]) was recommended. This was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the Via disc procedure.

The patient is an adult female with axial low back pain who underwent multiple procedures including radio frequency ablation. She has tried various medications as well as conservative treatment. Intra-discal allograft injections (VIA DISC NP [nucleus pulposus]) was recommended. This was denied coverage by the health plan as experimental/investigation. This denial is being appealed. The requested procedure has not been shown in the literature to be effective. It has not been shown in reproducible randomized clinical trials to be effective. While there is a small randomized clinical trial, there was no statistically significant difference between allograft injection and saline injection. In fact, all three arms, including placebo showed improvement. There was no obvious superiority shown in the treatment group. Given the lack of literature evidence to support the efficacy and given the fact that 11 out of 141 patients had complications, the requested procedure is not medically appropriate. 
The requested Via disc procedure is not more beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Axial Lower Back Pain and Intervertebral Disc 
Degeneration
Treatment: Via Disc Procedure (percutaneous injection of 
allogeneic cellular and/or tissue-based product intervertebral disc unilateral bilateral injection with fluoroscopic guidance code 0627T)
The insurer denied: Via Disc Procedure (percutaneous injection of allogeneic cellular and/or tissue-based product intervertebral disc unilateral bilateral injection with fluoroscopic guidance code 0627T)
The denial is upheld.

The patient is an adult female that presented with a history of axial low back pain. The patient is status post lumbar RFA (radio frequency ablation) six weeks prior. The patient did not achieve any significant benefit. The patient's pain is 8/10. The patient's pain is noted to be throbbing and aching. The pain is aggravated with rolling over in bed at night, turning head. The patient's lumbar examination revealed paravertebral muscle tenderness, SI (sacroiliac) joint tenderness; and positive facet loading lumbar bilateral with positive Fortin's sign bilateral left greater than right.

The health plan should not cover the requested Via disc procedure. Based on the provided documentation and per current literature studies, the requested procedure is still considered investigational. Though there have been some studies that provide some evidence, they continue to support the need for larger studies to support efficacy and safety. As such, the requested procedure at this time is still considered investigational.

The requested Via disc procedure is not more beneficial, as it is still considered to be investigational.