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

Diagnosis: Orthopedic/Musculoskeletal/Back Pain.
Treatment: Surgical Services (All).
The health plan denied the requested Intracept procedure. 
The health plan's determination is upheld.

The patient is a female with complaints of low back pain. The patient presented for an office visit. There is low back pain, which does not radiate, described as aching, throbbing and sharp. The pain is rated 7 out of 10. The pain is worse with activity. Medications include Celebrex. Physical exam demonstrated lumbar spine paraspinal muscle tenderness, extension 0-20. Facet loading maneuvers are positive. A magnetic resonance imaging (MRI) of the lumbar spine reported anterolisthesis of (lumbar) L4 and 5, disc uncovering with annular fissure, (lumbar-sacral) L5-S1 central disc protrusion. There is a request for the Intracept procedure.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

The proposed health service or treatment 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 has complaints of low back pain.
There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry Disability Index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain.
Treatment: Surgical Services (All).
The health plan denied the requested Intracept procedure. 
The health plan's determination is upheld.


This patient has severe low back pain. Her pain is aching, throbbing and sharp in quality. Pain level is 7/10. She had tried physical therapy (PT), pain medications and lumbar transforaminal injections without adequate improvement. A physical exam (PE) revealed tenderness to palpation (TTP) in the lumbar paraspinal region and positive facet-loading test. A magnetic resonance imaging (MRI) revealed (lumbar) L4-5 level, Grade 1 anterolisthesis, ligamentum hypertrophy and facet hypertrophy with severe spinal stenosis and moderate bilateral foraminal stenosis, impingement of exiting L4 nerve root, (lumbar-sacral) L5-S1 level with mild retrolisthesis, right eccentric disc bulge contracting descending (sacral) S1 nerves, and moderate right and mild left neuroforaminal stenosis with impingement of the right L5 nerve.
The issue is whether this patient is an appropriate candidate for Intracept procedure based on her history, physical exam, image findings and current clinical evidence.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

The proposed health service or treatment spinal procedure is unlikely to be beneficial for the insured's medical condition. The Intracept system was designed to treat low back pain from the vertebral body by ablating intraosseous nerves. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. Her MRI revealed Grade 1 anterolisthesis, ligamentum hypertrophy and facet hypertrophy with severe spinal stenosis and moderate bilateral foraminal stenosis, impingement of exiting L4 nerve root at L4-5 level with mild retrolisthesis, right eccentric disc bulge contracting descending S1 nerves, and moderate right and mild left neuroforaminal stenosis with impingement of right L5 nerve, L5-S1 level. The physical exam was remarkable for facet load test and TTP in paraspinal regions, which suggested facet arthritis might contribute to her symptomology. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with radiographic evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. [1]
Given this patient's medical history of severe spinal stenosis and disc bulge with nerve impingement, positive facet loading on physical exam, and the current clinical studies on the Intracept procedure, the patient is not an appropriate candidate for this procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with hyperlipidemia and chronic cough, who presented to the Emergency Room (ER) with fevers, shortness of breath and worsening cough. Patient was found to have left lower lobe pneumonia and viral panel showed Human Meta Pneumovirus. Patient was given oxygen, Intravenous (IV) antibiotics and duonebs. Patient was admitted to acute in hospital level of care. Patient continued to receive supplemental oxygen due to ambulatory hypoxia. Patient was started on oral Prednisone as well during the hospital stay. The acute in hospital level of care is denied due to lack of medical necessity. This denial is being appealed.

Yes. The proposed treatment is medically necessary.
Patient presented to Emergency Room (ER) with hypoxic respiratory failure due to pneumonia. Despite emergency room care, patient continued to have worsening symptoms and hypoxia. Although, the blood work was within normal limits, the patient had persistent cough and SOB (shortness of breath) as well as ambulatory hypoxia which improved slowly. The requested hospitalization is medically necessary as it was difficult to treat the patient's viral infection, causing prolonged hypoxia with minimal ambulation. The acute hospitalization is considered the current standard of clinical practice.

No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient had persistent cough and shortness of breath (SOB) as well as ambulatory hypoxia which improved slowly. The requested hospitalization is medically necessary as it was difficult to treat the patient's viral infection, causing prolonged hypoxia with minimal ambulation. The acute hospitalization is considered the current standard of clinical practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough and Fever. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male with a history of diabetes and status post stroke. He presented to the emergency department with one week of productive cough with fever and chills. His symptoms were associated with one day of lethargy and confusion. He had been on azithromycin for three days. 

The patient's Vital Signs were as follows: Temperature = 98.8, Max temperature = 101.3, Pulse = 70, Respiratory Rate = 20, Blood Pressure = 103/50, Pulse oxygenation 97%. The patient's exam was remarkable for decreased lung sounds in lower lobes. His labs were as follows: White blood cells (WBC) = 12.4, Hemoglobin/Hematocrit (H/H) = 11.2/31.4, Platelet (Plt) = 97, Sodium (Na) = 131, Potassium (K) = 4.1, Blood urea nitrogen/Creatinine (BUN/Cr) = 25/1.1, Glucose = 268. Chest x-ray showed small left pleural effusion vs basilar airspace disease. 

The patient was admitted with community acquired pneumonia. Plan of care included IV (intravenous) antibiotics. He remained afebrile during hospital stay. IV (intravenous) antibiotics were continued. He was discharged. 

Yes, the Inpatient admission was medically necessary. 

CURB-65 (confusion, blood area nitrogen, respiration rate, blood pressure, Age 65+ [plus]) uses five prognostic variables in providing a risk assessment for patients with community acquired pneumonia: Confusion; Urea > [greater than] 7 mmol/L (millimoles per liter) (20 mg/dL [milligrams per deciliter]); Respiratory rate 30 breaths/minute; Blood pressure (BP) (systolic < [greater than] 90 mmHg [millimeters of mercury] or diastolic 60 mmHg [millimeters of mercury]); and Age 65 years.  A CURB-65 (confusion, blood area nitrogen, respiration rate, blood pressure, Age 65+ [plus]) score of 0 to 1 indicates low risk and can be treated as outpatient; a score of 2 should be admitted to the hospital; and those with a score of 3 or more should be assessed for care in the intensive care unit. This patient's score was 3: confusion, BUN (blood urea nitrogen) 25, and age = 85. Hospital admission was indicated for this patient with moderate risk of community acquired pneumonia. Therefore, the Inpatient admission was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The Inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment braces, monthly visits, and a retainer

The insurer denied coverage for braces, monthly visits, and a retainer

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due excessive overjet. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required stating the patient exhibits the automatically qualifying condition of overjet greater than 9 mm (millimeters) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9mm with incompetent lips or reverse overjet with reported masticatory/speech difficulties and deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition is met and supports comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Overturn denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

The insurer's denial of coverage for the braces, monthly visits, and a retainer is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Diverticulitis and Abscess
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a female. She presented to the ER (emergency room) with three days of LLQ (lower left quadrant) abdominal pain.

The patient was hemodynamically stable, with LLQ tenderness. WBC (white blood count) was 8.9. CT (computed tomography) revealed diverticulitis with a 2.9 cm (centimeters) abscess. She was placed on IV (intravenous) antibiotics and kept NPO (nothing by mouth). Her pain persisted.

CT scan was repeated and revealed diverticulitis without abscess. The patient's diet was advanced and she was discharged.

Yes, the inpatient hospital admission was medically necessary.

The patient presented with three days of acute abdominal pain and was found to have complicated diverticulitis with a 2.9 cm abscess. Per standard of care, as well as MCG (Milliman Care Guidelines), inpatient hospital stay is medically necessary for complicated diverticulitis with abscess. Therefore, acute inpatient admission was medically necessary. A follow up CT scan revealed resolution of the abscess, and her diet was advanced and tolerated. Therefore, acute inpatient hospital stay was medically necessary, and the patient was medically stable for discharge.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity and Type I Diabetes Mellitus. 
Treatment: Ozempic 0.25 - 0.5 MG Dose Pen. 

The insurer denied the Ozempic 0.25 - 0.5 MG Dose Pen. 
The denial is upheld. 

This is a female diagnosed with obesity and type one diabetes mellitus (T1DM). This request is for Ozempic. As reported, the patient has been unsuccessful in losing weight with diet and exercise regimen alone. Her glycemic control is poor with glycated hemoglobin (A1C) of 8.2 %- 8.7 %. Her body mass index (BMI) was 43.6. She was given Ozempic sample with reported five pound weight loss in approximately one month. She has steadily lost weight and improved her blood glucoses (BGs). Her glycated hemoglobin (A1C) has gone from 8.1 % to 7.3%-7.6%.  

No, the proposed treatment with Ozempic is not medically necessary. 

Semaglutide is a glucagon-like peptide-one receptor agonist (GLP1R) [1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity  [2, [3, [4]. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity [5, [6, [7]. This medication is now available for the treatment of obesity in another form. There are no studies showing safety or efficacy of the requested Ozempic medication for patients who do not have type II diabetes such as this patient. There are no extenuating circumstances in this case. Other options in the same class that are Food and Drug Administration (FDA) approved for this indication exist. The request is therefore not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient as the request is not medically necessary as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient stay.

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

The patient is a man who presented to the emergency department (ED) with a complaint of abdominal pain of 4-days duration. It was associated with nausea and vomiting and a reported fever. He has a history of diverticulitis treated with colon resection and colostomy. The stoma was reversed. At the time of presentation to the ED, he reported right lower abdominal pain. His heart rate at the time of presentation was 88/minute. The other vital signs were normal. The abdomen was diffusely tender. The patient had been evaluated with x-rays that showed several nonspecific mildly dilated small bowel loops with air-fluid levels. A computed tomography (CT) scan of the abdomen and pelvis showed diffuse thickening of small bowel loops possibly related to an infectious or inflammatory process. The patient was admitted to the hospital for observation.

The inpatient hospital admission was not medically necessary.
The medical records support that this patient presented to the ED with abdominal pain. He was hemodynamically stable at the time of presentation and had CT scan findings of pathology involving the small bowel. The precise nature of this pathology was uncertain; however, he was admitted to the hospital for observation per the surgical notes. It was not thought that acute surgical intervention would be required.
He was appropriately evaluated for his presenting condition with physical exam, labs, imaging, and surgical consultation. He left the hospital against medical advice (AMA). The records support that a lower level of care would have satisfied the clinical needs of this patient. An inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Enamel Hypoplasia.

Treatment: Procedure D2740, tooth/quadrant 02, porcelain crown.

The insurer denied coverage for procedure D2740, tooth/quadrant 02, porcelain crown.

The denial is overturned.

Based on the submitted documentation which includes copies of bitewing and periapical radiographs, intraoral clinical photographs, and insurer correspondence, it appears that this patient presented for dental care. A failing long- standing crown restoration, was noted on # (number) 2 which exhibited fracture clinically. Currently the dentist is requesting replacement of the crown due to fracture and patients marked enamel hypoplasia. The insurer has denied the full coverage crown stating 'that the service is not medically necessary as the documentation did not demonstrate medic need to support the treatment, such as caries or a missing crown or damage to the existing crown and therefore the circumstance does not fulfill stated criteria for approval. 

Upon review of radiographs, it supports the recommended treatment. Tooth #2 exhibits a crown with open margins on both the mesial and distal aspects of the tooth as well as possible recurrent caries, consistent with a failing existing restoration. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a replacement crown and adequate residual periodontal alveolar bone height. Further the intraoral clinical photographs demonstrate significant generalized enamel hypoplasia. The standard of care in general dental practice would be replacement crown which would have an excellent long-term prognosis with the recommended treatment.

Overturn denial and approve coverage for procedure D2740, tooth/quadrant 02, porcelain crown as medically necessary as the clinical and radiographic documentation supports this service, and this service would be a standard of care in general dental practice.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Procedure D2740, tooth/quadrant 02, porcelain crown is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for procedure D2740, tooth/quadrant 02, porcelain crown is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Arm Weakness. 
Treatment: MyPro (L8702) (power custom brace). 

The insurer denied the MyPro (L8702) (power custom brace). 
The denial is overturned. 

The patient is a male with a diagnosis of paralytic syndrome resulting in left upper extremity paralysis since diagnosis of lung cancer and brain lesions. 

He was prescribed a left upper extremity power custom brace (MyPro - L8702), but it was denied coverage by the health plan as experimental/investigational. 

Yes, the health plan should cover the requested health service. 
There is significant medical literature showing that power custom brace (MyPro - L8702) improves upper limb function in individuals with upper limb paresis (see references below). 

The power custom brace (MyPro - L8702) is at least as beneficial as traditional neurorehabilitation in the treatment of this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Arm Weakness. 
Treatment: MyPro (L8702) (power custom brace). 

The insurer denied the MyPro (L8702) (power custom brace). 
The denial is upheld. 

The patient is a male with a history of metastatic lung cancer to the brain which resulted in a chronically weak upper extremity. This weakness has limited his ability to perform independent activities of daily living. He has been treated with traditional therapies including physical therapy. The request is for a myoelectric upper extremity orthosis. It was initially denied; it is being reviewed upon appeal. 

No, the health plan should not cover the requested health service. 

The patient has chronic upper extremity weakness secondary to brain metastases from a diagnosis of lung cancer. The requested myoelectric upper extremity orthosis remains experimental/investigational. There is minimal literature demonstrating the safety and efficacy of this device for patients with brain metastases. The available studies are small, non-randomized controlled, and often industry sponsored. As such, final conclusions as to the efficacy of this device cannot be made. As such, it remains experimental/investigational. 

No, it is not clear that the device is more beneficial than standard treatments.