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

Diagnosis: Obesity. 
Treatment: Ozempic 0.25 or .5 pen injctr (injector). 
The insurer denied coverage for Ozempic 0.25 or .5 pen injctr. 
The denial is upheld. 

This request is for Ozempic. As per letter; patient states she has stroke, heart issues, Patent foramen ovale (PFO) closure, seizure, Borderline diabetic and obesity as well. She had all these issues for 7 years. She is currently on medication for the rest of her life. 

The policy criteria require the submission of medical records indicating a diagnosis of type II diabetes, which is the approved indication of Ozempic. The patient does not have type II diabetes. The patient has a diagnosis of obesity and prediabetes. The request does not meet the policy criteria. 

Semaglutide is a glucagon like peptide 1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy and Ozempic. There are no studies showing the safety or efficacy of the requested medication for patients who do not have diabetes, such as this patient. There are no extenuating circumstances in this case. 

The request does not meet the standard of care and is therefore 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 Ozempic 0.25 or 0.5 pen injctr (injector) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is upheld

 
This adult female with no significant medical history presented to the emergency department (ED) with 2-3 days of fever, flank pain, nausea / vomiting, and dysuria. Temperature was 104 degrees F in the ED, patient vomiting. Left costovertebral angle tenderness noted on exam. White Blood Cells 13,300. Computed tomography (CT) scan revealed pyelonephritis, possible small ileoileal intussusception also seen. Patient admitted, given intravenous (IV) fluid, IV antibiotics, parenteral analgesic. The patient's condition improved. 

The insurer has denied coverage for the inpatient admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. Per InterQual 2022, Acute Adult Infection/Pyelonephritis/Complex UTI criteria, patient fails to meet guidelines for acute inpatient care. These include acute kidney injury (AKI), renal calculus, renal obstruction, age>65, renal insufficiency, etc. 

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: Vasovagal syncope
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of hypertension (HTN), hyperlipidemia (HL), and diabetes mellitus type 2 (DM2) who was admitted with complaints of (c/o) syncope after spending all day in the sun and during a bowel movement with questionable seizure activity reported by wife. His vital signs were remarkable for a temperature (T) of 38.2 degrees Celsius. The physical exam was unremarkable. Imaging studies included an electroencephalogram (EEG) which was normal, transthoracic echocardiogram (TTE) which was within normal limits (WNL). An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without acute ischemia. The patient was diagnosed with a vasovagal syncope, dehydration, and urinary tract infection (UTI) and treated with intravenous fluids (IVF), telemetry, antibiotics, and an electroencephalogram (EEG). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) syncope associated with spending all day in the sun and during a bowel movement. The patient did not have structural heart disease, hematocrit (HCT) less than (<) 30, shortness of breath (SOB), persistent hypotension, or a family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, or conduction blocks. The patient did not have a subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma or cardiac arrest, or exertional syncope. For the urinary tract infection (UTI), the patient was hemodynamically stable, did not have acute severe kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, immunosuppression, urinary obstruction, coexisting urolithiasis, failure of outpatient treatment, abnormal anatomy, abscess formation, single kidney, or kidney transplant. The patient was diagnosed with vasovagal syncope, dehydration, and urinary tract infection (UTI) and treated with IVF, telemetry, antibiotics, and EEG. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
Asked to review the case of an adult with a past medical history of Sjogren's Syndrome that presented to the hospital with sharp intermittent chest pain for one week. On arrival to the hospital, vital signs were stable (BP [Blood Pressure] 125/75 millimeters of mercury {mmHg}, Pulse 71 beats per minute {bpm}).  Physical examination revealed no major abnormality. 12 lead electrocardiogram (EKG) revealed sinus rhythm with non-specific T wave inversions in the inferior leads. Serum troponin levels were not elevated (<0.01 nanograms per milliliter {ng/ml}) the patient was admitted to the hospital for monitoring and treatment. Echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF) (65% [percent]) with no evidence of valvular abnormalities. Exercise stress testing revealed no evidence of ischemia. The patient was diagnosed with non-cardiac chest pain and was discharged.

This patient presented with atypical chest pain and a past medical history of Sjogren's Syndrome. His pretest probability of coronary artery disease was low. (Reference 1) Utilizing the HEART score the patient was considered low risk. (Reference 2)  Utilizing the thrombolysis in myocardial infarction (TIMI) risk score the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3). Using the History, electrocardiogram, age, risk factor, and troponin (HEART) score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion
Treatment: Braces
The insurer denied the request for braces.
The denial is overturned.

The patient is a teenage male requesting orthodontic treatment. He has a Class II malocclusion with moderate upper and lower jaw crowding. The prior denial was due to handicapping index being 13. 

The requested health service is medically necessary. 

The patient has a deep impinging overbite (7 millimeters [mm]) with severe soft tissue impingement on the palatal gum tissue. This is an automatic qualifier according to the handicapping index scale. Also, the patient has a moderately severe overjet (5 mm) where his upper front teeth stick out too far from his lower front teeth. This big space discrepancy (called overjet) between the front of his lower front teeth and the back of his upper front teeth will not allow "anterior guidance" to take place during the chewing cycle. What normally happens during chewing is that the lower front teeth glide along the backs of the upper front teeth to "disarticulate" (that is, disconnect) the upper and lower back teeth. This disarticulation prevents the back teeth from banging together and causing trauma and fracturing. Without "anterior guidance," this disconnecting of the posterior teeth cannot happen and over time teeth can break or prematurely wear down. Orthodontic treatment is needed to correct the deep bite and the overjet problem. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: back pain
Treatment: pain management
The insurer denied Ablative Nerve Treatment in the Spine.
The health plan's determination is upheld. 

The patient is a male with complaints of chronic low back pain. The pain began several years ago. Prior treatments have included medications as well as lumbar injections. Pain can be as high as 6 out of 10. Pain impacts activities of daily living. A magnetic resonance imaging (MRI) lumbar of the spine demonstrated Modic type II changes L (lumbar)4, L5.

The Ablative Nerve Treatment in the Spine is not medically necessary for this patient.
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. An 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 treatment modality.
In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. As such, this request is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriasis
Treatment: Skyrizi
The insurer denied Skyrizi
The health plan's determination is upheld. 

The patient is a male with psoriasis (up to 75% (percent) body surface area involvement). He has a history of Hepatitis C treated with 8 weeks of Harvoni. The patient has tried and failed topical clobetasol for his severe plaque psoriasis. The patient's history of Hepatitis C has led to avoidance of methotrexate and cyclosporine, and phototherapy has been avoided due to the inability to take time off from work for in-office treatments.

Skyrizi is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Acitretin, and/or Phototherapy. The patient does have a history of treated Hepatitis C, but if this virus has been treated and eradicated, then use of Methotrexate is not inappropriate. Still, it is understood why Methotrexate would be avoided by the provider and patient if there are fears of lingering hepatitic damage. However, the current medical literature supports Acitretin and/or Phototherapy as among the most appropriate treatments for patients who have or have had viral hepatitis.
Particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, these preferred agents are as appropriate for the treatment of this patient's clinical scenario as is the requested Skyrizi. Therefore, Skyrizi is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis/cholecystitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who presented to the emergency department (ED) with a complaint of abdominal pain of several days' duration. He was admitted to the hospital. His vital signs included a normal temperature, heart rate and respiratory rate and blood pressure at the time of presentation. He was tender in the right upper quadrant. An ultrasound  showed a gallbladder with stones and a common duct of 4-millimeters (mm). Surgery was performed. The operative notes describe a laparoscopic cholecystectomy with cholangiogram for the diagnosis of acute cholecystitis. A laparoscopic cholecystectomy was performed without complication.
Following surgery the patient's diet was advanced and the pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting. At issue is the medical necessity of an inpatient stay.
An inpatient level of care was not medically necessary in this case.
This patient was a previously healthy male. Imaging and surgical consultation were performed and established the diagnosis of cholelithiasis/cholecystitis. At the time of presentation, the patient had normal vital signs and was without a fever. An ultrasound was completed. The perioperative and early post-surgical recovery were uncomplicated and the patient had normal vital signs and tolerated a diet on the first post-surgical day. He was deemed to be stable for discharge from the hospital. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of IV (Intravenous) fluid, surgical consultation, performance of cholecystectomy, and overnight care. There were no peri-procedure complications or other clinical issues.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical myelopathy
Treatment: Spine Surgery (Code: 22856) and Inpatient Admission
The insurer denied: Spine Surgery (Code: 22856) and Inpatient 
Admission
The denial is upheld.

The patient is an adult female. The patient had a history of cervical myelopathy diagnosed 3 years ago. The patient had prior surgery with C4-C6 anterior cervical decompression and fusion (ACDF) with a C5 corpectomy 3 years ago. The patient has been recommended for a C3-C4 and C6-C7 total disc replacement. Magnetic resonance imaging (MRI) showed markedly limited evaluation of C3-C4 due to artifact. There is a disc bulge of C6-C7 resulting in mass effect upon the spinal cord, which is mild. There is moderate to severe spinal canal stenosis that has progressed. The exam shows 5 out of 5 (5/5) strength except for finger abduction, which is 4/5, and the patient has a steady gait. Computed tomography (CT) scan showed a small disc osteophyte complex to the right with no substantial canal stenosis at C3-C4 and mild foraminal stenosis. There is moderate canal stenosis and mild-to-moderate foraminal stenosis at C6-C7. This is a review for a disc arthroplasty of C3-C4 and C6-C7.

The requested health service is not medically necessary.

The need for adjacent level disc arthroplasty would not be supported. The use of this procedure is considered an off-label use of the device based upon the current prescribing information for these devices. There is some literature showing that these hybrid procedures are beneficial adjacent to a fusion, but this is insufficient to support this as standard of care. Currently, the information is lacking to support this procedure as safe and efficacious and, thus, it would not be considered medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative Colitis

Treatment: Zeposia

The insurer denied coverage for Zeposia

The denial is upheld. 

The patient has ulcerative colitis. A colonoscopy and magnetic resonance elastography (MRE) showed colonic inflammation. The colonoscopic biopsies were read as a normal terminal ileum but chronic active colitis including acute cryptitis. The patient has been on prednisone. The patient was initially advised to start Entyvio but wanted to take an oral medication. It is reported that the patient has an allergy to Remicade. 

UpToDate has an article titled "Management of moderate to severe ulcerative colitis in adults." First line induction therapy for moderate to severe ulcerative colitis includes several biologic agents. Among the recommended medications are adalimumab, golimumab, vedolizumab, and ustekinumab. For patients who do not respond to infliximab, it is advised to switch to a biologic agent of a different class such as ustekinumab or vedolizumab or to a Janus kinase (JAK) inhibitor. 

The insurance company has offered multiple biologic agents including Humira, Stelara, and Xeljanz. The patient has not tried these medications. They are all approved by the Food and Drug Administration (FDA) for treatment of moderate to severe ulcerative colitis. There is no evidence that the formulary drugs are likely to cause an adverse reaction. The formulary drugs have not been tried, so they have not been shown to be ineffective. It is not known at this time whether Zeposia would be more effective than the formulary alternatives. Since there are multiple formulary alternatives being offered for treatment of moderate to severe ulcerative colitis that have not been tried and failed, the denial is upheld.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Zeposia to treat ulcerative colitis is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pseudoseizures, multiple sclerosis, and restless legs syndrome.
Treatment:  Increase Consumer Directed Personal Care Assistance to 40 Hours per Week.
The insurer denied Increase Consumer Directed Personal Care Assistance to 40 Hours per Week.  The denial is upheld.

This adult male patient has medical conditions that include pseudoseizures, multiple sclerosis, and restless legs syndrome. The denial of an increase in consumer directed personal care assistance to 40 hours per week is being appealed. The health plan approved 15 hours per week. Uniform Assessment System (UAS) evaluation completed 5 months ago shows modified independent cognition and functional status; total dependence with meal preparation, housework, and managing finances; maximal assistance with shopping; limited assistance with bathing and dressing; supervision with managing medications; and independent with phone use, personal hygiene, walking, locomotion, toileting, bed mobility, and eating. The patient's wife cooks meals, manages finances, shops, and provides transportation. The patient has infrequent bladder incontinence.

The requested health service is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has chronic medical conditions. The denial of an increase in consumer directed personal care assistance to 40 hours per week is being appealed. The health plan approved 15 hours per week. Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires assistance with meal preparation, housework, managing finances, shopping, bathing, and dressing. He has infrequent bladder incontinence. The information provided does not support that the patient has functional needs requiring personal care assistance to 40 hours per week. The patient's wife cooks meals, manages finances, shops, and provides transportation. The approved personal care assistance to 15 hours per week is adequate to meet this patient's needs for assistance with activities of daily living that are not provided by his wife.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic brain injury. 
Treatment: Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week
The insurer denied Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week
The health plan's determination is upheld. 

This is a male patient with a history of a traumatic brain injury (TBI), seizure disorder, Alzheimer's disease, atherosclerotic heart disease, hypertension, heart failure, schizoaffective disorder, bipolar disorder, Parkinsonism, restless leg syndrome, cervical radiculopathy, and bowel and bladder incontinence. He lives alone in a private residence.  

The Personal Care Services (PCS) for 24 hours per day, 7 days per week (split-shift) for a total of 168 hours per week is not medically necessary. 
Although the patient requires hands-on assistance with many activities of daily living (ADL) and Instrumental activities of daily living (IADL), the documents provided do not support a claim of medical necessity for split-shift care. Split shift care is indicated if a live-in personal care aide would not be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep due to a patient requiring assistance with ADLs. There is no documentation showing that the patient currently requires frequent overnight assistance with specific ADLs or IADLS. There were no night-logs of care required overnight and no physician orders for frequent repositioning or assistance with specific ADLs at specific intervals. Therefore, there is insufficient evidence of medical necessity for split-shift care.