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

Diagnosis: Back Pain. 
Treatment: Intracept Procedure. 

The insurer denied the Intracept Procedure. The health plan's determination is upheld. 

The patient is a female with chronic lower back pain (LBP) for > (greater than) 15 years causing significant impact on her activities of daily living (ADL) including walking even short distances. The patient has a very complicated PMHX (past medical history) including hypertension (HTN), migraine headache, myofascial pain syndrome, morbid obesity, chronic ankle pain and thoracic/lumbar radiculopathy, sacral joint pain, scoliosis, lumbosacral spondylosis, disc herniations, and spinal stenosis. She was involved in a serious MVC (motor vehicle collision) resulting in knee, back and jaw pathology. Medications included aspirin, baclofen, gabapentin, lysine, nadolol, and Protonix. She is allergic to Celebrex and sulfadiazine. She had a h/o tobacco abuse and occasional alcohol use. The patient has had multiple interventions over the years and has used nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and opioids to treat her pain. She has had multiple facet blocks, multiple radiofrequency ablation (RFA), rhizotomy, epidural steroid injection (ESI), and a Medtronic dorsal column stimulator (SCS). 

The 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. 
In this case, the patient appears to have significant physical limitations due to her chronic LBP. The requesting physician notes that the patient's pain is significant and limits walking, but there is no ODI (Official Disability Index) score or specific explanation as to the degree of limitations. Furthermore, the lumbar MRI appears to be from a few years ago and while the pain physician notes Modic changes, these are not included in the radiologist report included. Due to the time interval, the Modic changes, if present might have progressed to type 3, which may not be as amendable to the Intercept procedure. The documentation in this case is limited and does not describe in detail the long and complicated management, as well as responses to the therapies performed. This makes it difficult to opine on the contribution of many of the diseased anatomic structures/pathology as the etiology of her pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intracept Procedure. 

The insurer denied the Intracept Procedure. The health plan's determination is upheld. 

The patient is a female with a long history of low back and lower extremity pain. She has had multiple pain management interventions over several years including various epidural steroid injections, lumbar medial branch radiofrequency neurotomy and implantation of a spinal cord stimulator. In the past, there appears to have been transient but marked relief of symptoms with epidural steroid injections. Her current symptoms include severe low back pain, bilateral lower extremity pain and dysesthesia with ambulation. Ambulation is significant limited. There is urinary incontinence. The most recent lumbosacral magnetic resonance imaging (MRI) is 3 years old. In addition to severe multilevel spondylosis with Modic I type endplate changes at L (lumbar) 2-3 and L5-S (sacral)1, there is reported severe central canal stenosis "possible cauda equina compression" at L3-4. 

The 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. 
This patient presents with symptoms and signs most consistent with severe spinal stenosis and neurogenic claudication. Furthermore, an MRI from nearly three years ago is being utilized for decision making; however, that MRI may not represent the current status of the vertebrogenic changes. Despite the presence of Modic I endplate changes on a three year old MRI and the presence of lower back pain (LBP), the preponderance of evidence indicates that severe spinal stenosis and perhaps impending caudal equina syndrome are the most likely cause of her debilitating symptoms. Basivertebral nerve RF (radiofrequency) ablation (Intracept procedure) is not indicated for the treatment of spinal stenosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intracept Procedure. 

The insurer denied the Intracept Procedure. The health plan's determination is upheld. 

The patient is a female with a history of hypertension (HTN) and migraines who has lower back and buttock pain with radiating pain to the lower extremities (left greater and right). She has tingling and numbness sensation in the lower extremities with urinary incontinence. Pain level 5/10 to 10/10. Her pain is worse with physical activities, walking and prolonged standing. She cannot walk for a short distance without stopping due to pain. The patient had a motor vehicle accident (MVA) that resulted in knee, jaw and back injuries. An magnetic resonance imaging (MRI) from a few years ago revealed multi-level lumbar disc herniations. She underwent facet rhizotomies, nerve blocks and epidural injections with minimal relief, and had a dorsal column stimulator implant. 

The 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 Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. The MRI revealed severe spinal stenosis with possible cauda equine compression at L3-4 level. She has urinary incontinence and other symptoms consistent with severe neurogenic claudication. 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. 
Given this patient's severe spinal stenosis and her symptoms of neurogenic claudication, she is not an appropriate candidate for the Intracept procedure.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acute myocarditis, cardiomyopathy
Treatment: Formulary exception for Coreg CR, Pre-service
The insurer denied the formulary exception for Coreg CR, Pre-service.
The denial is upheld.

The patient is a female. She presented with acute myocarditis and developed a cardiomyopathy several years prior. Her complete work up included endomyocardial biopsy. She was placed on optimal medical therapy. In addition to Entresto, she was placed on Coreg CR (continuous release), spironolactone, Eliquis and ASA (aspirin).

The use of branded once a day Coreg CR was denied coverage by the health plan as being non-formulary.

There was no documentation of use and failure of generic Coreg, nor was there documentation of use or failure of other beta blockers.

No, the health plan should not cover the formulary exception.

There was no documentation of failure of generic Coreg or other beta blockers. Review of literature is consistent with the use of generic Coreg in successful treatment of chronic CHF (congestive heart failure).

Coreg has been studied and used for more than 10 years, and no study has shown advantage of Coreg CR other than the convenience of once a day use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: RSV Infections (chronic respiratory failure)
Treatment: Synagis
The insurer denied the Synagis.
The denial is overturned.

The patient is a male child born prematurely with the following complicated medical history: chronic respiratory failure requiring tracheostomy and mechanical ventilation, pulmonary hypertension secondary to chronic lung disease, dysphagia with gastrostomy dependence, tracheomalacia, and patent ductus arteriosus medically managed. He has had multiple episodes of tracheitis and pneumonia consistent with his chronic lung disease and chronic respiratory failure.

Yes, the requested Synagis for RSV (Respiratory Syncytial Virus) prophylaxis is medically necessary and appropriate.

The American Academy of Pediatrics issued new guidelines for the administration of Synagis for RSV prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease. The following groups of patients are considered at highest risk, with recommendations for administration of Synagis: infants born before 29 weeks' gestation younger than 12 months of age at the start of RSV season; infants with chronic lung disease of prematurity born before 32 weeks' gestation during the first year of life, with some consideration during the second year of life if continued medical support is necessary; infants 12 months of age or younger with hemodynamically significant congenital heart disease (excluding those with lesions adequately corrected by surgery unless medication is necessary for ongoing congestive heart failure); consideration for infants 12 months of age or younger with anatomic pulmonary abnormalities or neuromuscular disorders that have difficulty clearing secretions; consideration for infants less than 24 months of age that are profoundly immunocompromised; and consideration for infants with Down syndrome or cystic fibrosis that have evidence of other risk factors such as chronic lung disease or congenital heart disease.

This infant was denied coverage based on the duration of administration (more than five doses).

The request is for dose administration. According to CDC (Centers for Disease Control and Prevention) surveillance data, RSV has been detected in the area in which the child resides, and only since approximately the middle of the first month of the year has it begun to fall below the 10% detection rate. There will be lingering exposure through approximately the next two months. The requested Synagis prophylaxis is thus medically necessary and appropriate for this high-risk child for the time frame in question.

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

Diagnosis: Atrial Fibrillation
Treatment: Formulary exception for Eliquis
The insurer denied the formulary exception for Eliquis.
The denial is overturned.

The patient is a male on chronic anticoagulants for atrial fibrillation and DVT (deep venous thrombosis). Eliquis was initially well tolerated, but switched to Xarelto due to the health plan's formulary preference. This was accompanied by epistaxis. Lower doses of Xarelto were attempted, but were felt to be insufficient for his conditions. He was then switched to Eliquis, which was accompanied by resolution of his epistaxis.

Yes, the health plan should cover the formulary exception for Eliquis.

The patient has clear indications for anticoagulants, with both atrial fibrillation and DVT. The preferred formulary medication, Xarelto, was accompanied by adverse epistaxis. This did not occur with Eliquis. This clinical history was well-documented in both the appeal letter and medical records.

Since the formulary drug had complications, it is appropriate to go off formulary. The indications for DOAC (directly acting oral anticoagulants) are well described in this clinical situation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CHF/Hypertension
Treatment: Home health care
The insurer denied Personal Care Services, Level II - 8 Hours per Day, 7 Days per Week (Total of 56 Hours per Week). The health plan's determination is overturned. 

The patient is a  female with past medical history of hypertension with renal disease, peripheral artery disease, anemia, venous insufficiency, obesity, history of cerebrovascular accident (CVA), and urinary incontinence who had been assigned PCA (personal care assistant) services. The patient was hospitalized with new onset atrial fibrillation and congestive heart failure. The patient was transferred to rehabilitation with a request to increase PCA services when planning for discharge from rehabilitation. The patient underwent and assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, transportation, bathing, transfer toilet, and toilet use. With tasks of managing finances, managing medication, personal hygiene, dressing upper body, dressing lower body, walking, locomotion, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of phone use and eating. Notes from the assessment noted the patient had a decline in activities of daily living (ADL) status compared to 90 days ago as well as a deterioration of overall self-sufficiency compared to 90 days ago. The assessment also stated the patient lived alone.

Personal Care Services, Level II - 8 Hours per Day, 7 Days per Week (Total of 56 Hours per Week) are medically necessary for this patient.
There is documentation from the patient's medical provider of worsening functional status of the patient. The assessment  stated the patient required at least maximum assistance with transfer toilet and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient would need PCA services outside of the time that she has informal or formal help. The patient's needs cannot be met solely with medical equipment and adaptive supplies. The patient has increased care needs following hospitalization with new medical diagnoses of atrial fibrillation and congestive heart failure (CHF) and subsequent rehabilitation stay. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8 hours/day, 7 days/week, to total 56 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Deep Vein Thrombosis
Treatment: Eliquis

The health plan denied the requested prescription drug Eliquis. 
The health plan's determination is upheld.

This is a male with a left lower extremity deep vein thrombosis on long term anticoagulation with Eliquis. Eliquis was denied as the formulary alternatives are Warfarin and Xarelto; this is under review.

The health plan's determination is upheld, in whole.

Neither Xarelto nor Warfarin have been demonstrated to be inferior to Eliquis. The included documentation does not indicate that this patient is intolerant of either of the formulary alternatives nor that he has failed them; similarly, there is a paucity of documentation indicating this patient has a contraindication to the formulary alternatives. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient presented to the hospital emergency department (ED) with abdominal pain. His past medical history was notable for asthma. He was without a fever at the time of presentation. He had tenderness in the left lower quadrant of the abdomen. His initial evaluation included lab data that identified a leukocytosis of 11.2 thousand (K). A computed tomography (CT) scan identified acute sigmoid diverticulitis with micro-perforation. He was treated with intravenous (IV) antibiotics, intravenous (IV) fluid and nothing by mouth (NPO) status. A surgical consultation was obtained. He was admitted to the hospital.

He was receiving IV Zosyn. His vital signs were normal. The physical exam showed tenderness to palpation in the lower quadrants. The WBC count was normal (9.2 K). He was kept nothing by mouth (NPO) and received IV fluids.

He was still tender but was started on a clear liquid diet. Once he demonstrated tolerance of the diet he, was discharged from the hospital  with continued oral antibiotics.

At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was medically necessary and consistent with the standard of care.
This patient presented to the hospital with acute perforated diverticulitis. This diagnosis was confirmed by a CT scan that demonstrated extraluminal air adjacent to inflamed sigmoid colon. He was appropriately admitted to the hospital and treated with nothing by mouth (NPO) status and IV antibiotics. He was receiving IV fluid during this time. This clinical condition carries the significant potential for rapid clinical deterioration and warranted an inpatient level of care. It was also reasonably anticipated based on his presenting condition that his condition and need for inpatient care would span a period of greater than 2 nights. While he did respond favorably to non-surgical therapy there was need for surgical assessment and follow up.

The Milliman Care Guidelines (MCG) 25th ed-Diverticulitis, Acute. Inpatient & Surgical Care support an inpatient level of care for this patient as he had peritoneal signs on examination and the significant imaging finding of perforation of the sigmoid diverticulitis. He required a period of NPO status with the provision of IV fluids. The patient did have the potential for rapid clinical deterioration and required the administration of IV antibiotics and close clinical follow up. He remained with lower abdominal tenderness.

Inpatient care was most appropriate for this patient based on his presenting condition, the reasonable anticipation that his care would span a period of at least 2-nights, his imaging findings, need for NPO status, and need for IV antibiotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient was brought to a different hospital's emergency department (ED) with a one day history of right lower quadrant abdominal pain. The ultrasound, computed tomography (CT) scan, and lab results were all unremarkable in the ED. The ED records documented that the "patient still has significant tenderness to right lower quadrant/McBurney's point to palpation. I believe the patient requires pediatric surgery consult as well as possible serial abdominal exam." The patient was transferred directly to the inpatient floor of the hospital. On presentation, her vital signs were normal and her exam was normal and her pain was gone. She was admitted for observation and sent home the next day. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.
The patient was accepted for admission to the pediatric floor of the hospital as an Emergency Medical Treatment & Labor Act (EMTALA) transfer from a different emergency department. Since the referring facility said the patient required admission, the receiving hospital, if it had the ability to care for the patient (e.g. sufficient staffing, space, expertise), was obligated to accept the patient.  The receiving hospital, however, was not obligated to keep the patient in the hospital overnight.  The receiving hospital re-evaluates the patient in real time and can implement its own plan based on the information. The patient had abdominal pain which had resolved by the time the patient arrived and the patient had a complete negative laboratory and radiographic workup hours before at the initial ED. On presentation, her vital signs were normal, her exam was normal and her pain was gone. The patient did not need to stay overnight and could have been promptly discharged from the receiving hospital after the re-evaluation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Ulcerative Colitis.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned, in whole.

This is a male with a history of ulcerative colitis complicated with primary sclerosing cholangitis (PSC) off medical therapy who presented to the emergency room with progressive abdominal pain, hematochezia, and symptomatic acute blood loss anemia. Labs were noted for a mild acute blood loss anemia, transaminitis, and dehydration on admission. He was admitted to the inpatient floor and received intravenous (IV) fluids, serial lab monitoring, and a gastroenterology consultation. The consultant recommended a diagnostic magnetic resonance cholangiopancreatography (MRCP) to evaluate for abnormal liver function and prompt initiation of IV steroids for an ulcerative colitis flare. The patient improved clinically with episodic hypotension and persistent anemia. He was transitioned to oral steroids and was discharged home for follow-up with a diagnostic colonoscopy with gastroenterology.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned, in whole.

Yes. Inpatient care was medically necessary. This is a patient with a history of ulcerative colitis (UC) complicated with PSC who is off medical therapy presenting with a UC flare characterized by hematochezia, anemia, and abnormal liver function tests (LFTs). This was characterized by abdominal pain, rectal bleeding/hematochezia, tenesmus, decreased oral intake in the setting of abnormal transaminitis. He is a high-risk patient for complications of a UC flare because of his young age, being off medical therapy and (PSC). He requires prompt inpatient care, including IV steroids, IV antiemetics, IV analgesic to correct azotemia, and serial lab monitoring for anemia and abnormal liver function tests and a gastroenterology consultation for evaluation and management of his UC flare to prevent inflammatory bowel disease (IBD) related complications (acute blood loss anemia intra-abdominal abscess, perforation, and colectomy from an uncontrolled UC flare). The patient was promptly started on IV steroids in combination with Mesalamine to manage his ulcerative colitis flare and was restarted on Ursodiol to manage his PSC.
This detailed inpatient management cannot be provided at an alternate level of care.