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


Diagnosis: Obesity.
Treatment: Mounjaro 5 milligram (mg)/0.5 milliliter (mL) Pen Injector.
The insurer denied the Mounjaro 5 mg/0.5 mL Pen Injector.
The health plan's determination is upheld.

The patient is a female with Insulin resistance and fatty liver. Her body mass index 26.3 kilograms per meter squared (kg/m2). Prior to Mounjaro, the patient had obesity with a body mass index of 30.7 kg/m2, hypertension, non-alcoholic fatty liver disease, hyperlipidemia, hypertriglyceridemia, prediabetes, elevated Insulin levels, hemoglobin A1C (hgbA1C) of 5.4 percent (%), sleep apnea, multiple cardiac arrhythmias with first degree atrioventricular (AV) block, and a post-menopausal status.

The health plan in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The request for Mounjaro 5 mg/0.5 mL Pen Injector is not medically necessary. This request is for Mounjaro for weight loss. The prior request was denied because the patient does not have a diagnosis of type 2 diabetes and has not tried and failed or had an intolerance to two of the following: Ozempic, Trulicity, and Victoza. Mounjaro is indicated for type 2 diabetes, which is not documented in this case. The Mounjaro prescribing information does not support the use of Mounjaro in this clinical situation. The American Diabetes Association clinical guidelines do not support the use of Mounjaro for prediabetes or elevated Insulin levels or to prevent the development of diabetes. The Endocrine Society guidelines on the management of obesity do not support the off-label use of medications for weight loss. There are other commercially available medications that are indicated for weight loss. Mounjaro has risks, including nausea and vomiting.

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

Diagnosis: left gluteal abscess.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is an adult with a benign past medical history who presented to the emergency room with complaints of left-sided buttocks swelling and pain.

Vital signs and laboratory results were within normal limits.

Patient was empirically started on intravenous antibiotics (Unasyn). Patient underwent an incision and drainage procedure under local anesthesia, 20 cubic centimeters (cc) of purulent exudate was drained. Post-procedure course was unremarkable. Patient remained afebrile, hemodynamically stable and clinically improved. She was discharged to continue oral antibiotics as an outpatient.  

According to documentation, patient presented with a left gluteal abscess. The patient was afebrile and hemodynamically stable. Laboratory results were unremarkable including normal White blood cells (WBC) (9.0). The patient tolerated the incision and drainage procedure under local anesthesia. She had no co-morbid conditions, and no evidence of a systemic infection. Based on above findings, patient met criteria for observation level of management.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea/vomiting
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The health plan's determination is upheld. 

The patient is a female with a recent gastric sleeve admitted to the hospital with 3 days of nausea and vomiting. No abdominal pain was noted. She was sent to the emergency room (ER) after trying Zofran which was not beneficial. On admission, the patient was afebrile with normal vital signs. The patient underwent a computed tomography (CT) at time of admission which showed only post-operative changes. The patient was admitted for proton pump inhibitor (PPI), Carafate with plans for diagnostic esophagogastroduodenoscopy (EGD). 

The inpatient hospital admission was not medically necessary. The patient presented with nausea and vomiting that quickly responded to IV (intravenous) fluids and IV antiemetics. After time in the ER the patient was actually able to tolerate a liquid diet. The CT and labs were very reassuring and an inpatient upper endoscopy emergently was not necessary. In my opinion the patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male with a past medical history of seizure disorder on Keppra 1g (gram) twice daily, sickle cell disease, and systolic congestive heart failure with an ejection fraction of 45-55% who presented to the emergency department with seizure activity, which was not an unusual presentation for him as he had multiple previous admissions in the past due to medication non-compliance. 

Upon examination, the patient denied chest pain, headache, fever, chills, diarrhea, or constipation. The patient had one more witnessed seizure activity, which was aborted with 2mg (milligrams) of Ativan. He was loaded with Keppra 3g and took 1g of oral Keppra and received 1 liter of normal saline bolus.

The inpatient hospital admission was medically necessary.  

The patient presented to the hospital with a breakthrough seizure that resulted in rhabdomyolysis. The indications for admission at the acute inpatient level of care for patients with acute rhabdomyolysis depend on the severity of the condition and the presence of associated complications. In general, patients with severe rhabdomyolysis or those who are at risk of developing complications should be admitted to the hospital. In this particular case, the patient had significant rhabdomyolysis with creatine phosphokinase (CPK) levels dozens times higher than the upper limit of normal. The patient required administration of intravenous fluids and close monitoring of his kidney function and electrolytes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

Patient is an adult male who presented to the hospital on with complaints of shortness of breath (SOB), chest tightness and wheezing. Past medical history includes asthma, atrial fibrillation, congestive heart failure (CHF), and polysubstance abuse. He was recently discharged from the emergency department (ED) but was non-compliant with taking medications.

At presentation to ED, Blood Pressure was 147/89, Pulse 110, Respirations 20, and oxygen saturation 94% on room air. The patient was in no acute distress. Lungs revealed bilateral wheezes. Heart sounds were normal, abdomen soft, and he was alert and oriented x 3.

White Blood Cells 8.1, Electrolytes were within normal limits. Chest x-ray (CXR) showed no acute infiltrates. The patient was treated with intravenous (IV) steroids, bronchodilators via nebulizer and Magnesium. Patient improved after treatment in the ED and was switched to oral Prednisone, Mometasone inhaler and Singulair.

This patient did not need acute inpatient hospital stay. He could have been placed in observation status while diagnostic testing and treatment were initiated. He was treated with oral (PO) meds after admission. He could have been discharged home on PO meds after a period under observation with close follow up as an outpatient.

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


Diagnosis: COVID 19

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 

Patient is an adult female with past medical history significant for hypertension who presented to the emergency room with complaints of cough and shortness of breath.

Vitals on presentation included: Temperature 96.8 degrees, Blood Pressure 154/79, Pulse 71, Respiratory Rate 18, oxygen (O2) saturation 98 percent on room air. Laboratory values were notable for the following: white blood cell count (WBC) 8.4, hemoglobin (Hgb) 10.5, hematocrit (Hct) 33.5, creatinine (Cr) 0.85, glucose 97, C- reactive protein (CRP) 16, B-type natriuretic peptide (BNP) 367.5.

The patient was admitted to the hospital for COVD-19. Chest X-ray (CXR) showed prominence of central pulmonary vasculature and hazy opacity at the lung bases. The patient was treated with steroids, Lasix and intravenous (IV) Remdesivir. Patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management. 

Although COVID treatment and management guidelines continue to evolve, the decision to hospitalize patients with COVID infection is typically based on the presence of severe dyspnea (dyspnea at rest and interfering with the ability to speak in complete sentences), oxygen saturation on room air less than or equal to 90 percent (regardless of severity of dyspnea), alternations in mentation (i.e., confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Similarly, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of less than 94 percent on room air, respiratory rate of greater than  30 breaths/minute, or lung infiltrates greater than 50 percent. According to medical records, patient was afebrile, hemodynamically stable with normal oxygen saturation on room air. Moreover, she was described as "in no acute distress, breathing non-labored." 

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 stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine headaches

Treatment: Qulipta 60 milligrams (mg) OR tabs

The insurer denied coverage for Qulipta 60 milligrams (mg) OR tabs

The denial is upheld
 

This case involves an adult male who reportedly suffers from migraines, not intractable, with status migrainosus who was recommended for Qulipta 60 mg oral tablets.  A phone message stated the patient was having severe dizziness while on propranolol 10 mg and due to a diagnosis of depression, is unable to take Topamax because of interaction.  The patient has tried other medications that do not help to include trazodone 50 mg, trazodone 100 mg, Effexor, Nurtec, and Imitrex.  The telephone note claimed that Qulipta 60 mg was helpful with migraines when he received samples from the office.  The patient received a notice of adverse determination regarding Qulipta given that there were no records indicating the patient tried and failed or had a poor response to medication such as Aimovig, Ajovy, and Emgality.  An appeal was submitted stating that the patient has either tried and failed or is unable to take certain medications due to interactions.  The patient has 2 oral prophylactic failures and failure of a triptan.  This review pertains to Qulipta 60 mg oral tablets.

The Food and Drug Administration states that Qulipta is indicated for the preventative treatment of episodic migraine in adults.  Current literature notes that Qulipta has been approved for migraine prevention.  However, the physician did not address the prior determination issues in terms of the patient first trying formulary alternatives such as Aimovig, Ajovy, and Emgality.  Given that all 3 of these medications are also used to prevent migraines, it would be prudent for the physician to trial the patient on 1 or all of these medications initially before pursuing additional use of Qulipta.  As such, the request for Qulipta 60 milligrams (mg) OR tabs 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 Qulipta 60 milligrams (mg) OR tabs is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628, 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628, 64629)
The denial is upheld.

The patient is an adult female with low back pain. Previous treatments include sacroiliac joint injection and radiofrequency ablation. MRI (magnetic resonance imaging) of the lumbar spine shows no acute bone marrow edema and stable endplate marrow changes associated with degenerative disc disease compared to prior exam. The request for Intracept was denied coverage by the health plan as investigational. The denial is being appealed.

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

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628, 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628, 64629)
The denial is overturned.

The patient is an adult female with a history of chronic low back pain that began years prior. The patient has undergone activity modification, chiropractic care, home exercise, lumbar epidural steroid injections, physical therapy, radiofrequency ablations and SI (sacroiliac) joint injections. The pain is aggravated with bending, lifting and sitting. The patient reports pain as 8/10.
Per the appeals letter, the patient has chronic low back pain due to degenerative disc disease that resulted in development of vertebral genic pain identified by degenerative endplate changes. The patient has pain for greater than several months and failed treatment for greater than several months. MRI (magnetic resonance imaging) demonstrated moderate degenerative disc disease with endplate marrow changes at (lumbar) L3-L4, L4-L5 and L5 and (sacral) S1.

The health plan should cover the requested health service. 

The requested health service is more beneficial. Based on the documentation provided, the requested basivertebral radiofrequency ablation is recommended in this case. The patient has a history of chronic low back pain and despite prior conservative treatments, the patient continues to be symptomatic. Additionally, the patient has tried interventional treatments, including lumbar medial branch RFA (radiofrequency ablation), lumbar epidural steroid injection as well as activity modification, physical therapy and continued home exercises. The patient continues to be symptomatic with positive findings noted on exam as well as MRI (magnetic resonance imaging). As such, the request is appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628, 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628, 64629)
The denial is overturned.

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as 
experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, RFA (radiofrequency ablation), SI (sacroiliac) joint injections, PT (physical therapy) and home exercises. The patient has failed multiple medications, including NSAIDS (nonsteroidal anti-inflammatory drugs). Magnetic resonance image shows degenerative endplate changes/Modic changes. The patient's physical exam does not reveal any neurological injury.

The health plan should cover the requested health service.

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The procedure is a Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized clinical trials (RCT) with five-year results. The patient has failed common proven treatments for axial low back pain. The patient has failed conservative treatment in the form of chiropractic care, physical therapy, injections, radio frequency relation, and sacroiliac joint injections. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed, as shown above. Alternatives involve surgery and are more invasive and show less favorable outcomes in high-quality randomized controlled trials compared to conservative treatment. Given the above, the requested procedure is medically appropriate and should be covered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Monthly Braces Adjustment Visits. 

The insurer denied: Monthly Braces Adjustment Visits. 
The denial is overturned. 

The patient is a young adult male. The request is for orthodontic benefits, including monthly follow-up visits for adjustments to braces. The health plan's prior denial of coverage was due to a reported dental code being able to stop pain, disease, fix the patient's teeth and take care of the patient's dental health. Since a covered dental code could do all these things, the proposed treatment of continuing orthodontic care was deemed not medically necessary. The denial is being appealed. 

The Monthly Braces Adjustment Visits are medically necessary. 

The patient has a Class III malocclusion. This means that his bite is "reverse," and his lower teeth are "outside" of his upper teeth. This does not allow for the proper chewing of food and will also cause trauma and/or fracturing of the patient's teeth over time due to the teeth not meshing (interdigitating) properly during the chewing cycle. It will also likely cause TMJ (temporomandibular jaw) issues over time due to increase pressure on his temporomandibular joints. The patient needs the continuation of orthodontic treatment to help correct his occlusion after he has his jaw surgery. The orthodontic treatment is medically necessary to fine tune his bite after the surgery and allow all his teeth to mesh together properly when he chews. There is no other way to 
complete the treatment needed by this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: shoulder rotator cuff tear

Treatment: ambulatory surgery, procedure codes 29826 and 29827

The insurer denied coverage for ambulatory surgery, procedure codes 29826 and 29827

The denial is overturned

According to the documentation submitted, this is an adult with a history of chronic left shoulder pain and a left shoulder rotator cuff tear. The patient had a left shoulder arthroscopy with slap repair, biceps tenodesis, rotator cuff repair, subacromial decompression, arthroscopy, shoulder, with distal clavicle excision. 

The medical records showed consistency of subjective complaints and physical findings for shoulder pathology. The patient was seen on several occasions by different practitioners reporting left shoulder pain. The patient was noted to have problems with use and did not improve with a course of conservative treatment. The patient had attempted physical therapy (PT) which made the shoulder pain worse. The patient reportedly had undergone an injection. The patient was symptomatic for almost one year. 

The patient's imaging studies were not dramatic but nevertheless showed tendinosis to the cuff and biceps tendon. A pain generator had been defined with failure to improve with conservative treatment. This would be an indication for surgery. Although the magnetic resonance imaging (MRI) did not show labral pathology, intraoperative evaluation would be the most definitive diagnostic test. MRIs have been found to have false negative interpretation for Superior labrum anterior and posterior (SLAP) tears. 

The physician found pathology and a repair would be appropriate.

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 ambulatory surgery, procedure codes 29826 and 29827 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: stroke
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

This is a case review for a male who was admitted to the hospital for the diagnosis of cerebral infarction (unspecified) and symptoms of stroke.
The patient presented to the emergency department with complaints of right upper extremity weakness. He had a past medical history notable for stage intravenous (IV) duodenal carcinoma with liver metastases, reflux, and hypertension. A computed tomography (CT) of the head was negative for acute bleed. He was admitted for further workup and management.

The Inpatient Hospital Admission was medically necessary for this patient.
The patient presented with acute stroke symptoms, and this diagnosis was confirmed on magnetic resonance imaging (MRI) imaging. His symptoms met Milliman Care Guidelines (MCG) criteria for acute inpatient admission for stroke. He had significant arm weakness and findings that warranted inpatient physical therapy and occupational therapy evaluation. His presentation was also complicated by his cancer diagnosis and multiple embolic findings on MRI, which warranted additional investigation into the etiology of his symptoms.