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

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

This is a female patient who presented to the emergency department (ED) with the complaint of abdominal pain of 8-10 hours duration. Comorbid health conditions included obesity and asthma. She was evaluated with an examination, labs, and imaging. This assessment revealed right lower abdominal tenderness and computed tomography (CT) findings of uncomplicated acute appendicitis. The vital signs identified an elevated heart rate and temperature at the time of presentation. Surgical consultation was obtained. The patient was admitted to the hospital and started on intravenous (IV) antibiotics. She was treated with a laparoscopic appendectomy for acute appendicitis. The operation was completed without complication. The appendix was noted to be inflamed.
Following surgery, pain control was with oral medications and she was started on a diet. She was discharged from the hospital with instructions for surgical follow up.
At issue is the medical necessity of an inpatient admission.
Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated at a lower level of care.
This patient presented with abdominal pain. The evaluation with examination, lab data, and computed tomography (CT) scan supported the diagnosis of acute appendicitis. The diagnosis and indication for surgery was established and the patient was initially treated with intravenous (IV) antibiotics. Laparoscopic appendectomy was performed Following surgery to remove the appendix, she was clinically stable and was tolerating a diet. She was discharged with instructions for surgical follow up.
The patient was clinically stable at the time of presentation and remained so during the course of care. While she had an elevated white blood cell count (WBC) at the time of initial presentation, she was responding favorably and promptly to the prescribed treatment (antibiotics and appendectomy). A lower level of care would have provided for surgical assessment, provision of antibiotics, surgical care as performed and post-surgical monitoring.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypertension. 
Treatment: Diovan HCT 160/12.5 milligram (mg) tablet (valsartan-hydrochlorothiazide (HCTZ)). 
The insurer denied coverage for Diovan HCT 160/12.5 mg tablet (valsartan-HCTZ). 
The denial is overturned. 

This patient has a history of long standing hypertension. Blood Pressure (BP) has been controlled for several years on amlodipine and Diovan HCT. Her physician provided documentation that the patient failed to maintain blood pressure control on three alternative angiotensin receptor blocker agents including Valsartan, Olmesartan and Losartan. 

In this case Diovan HCT therapy is medically necessary. According to American Heart Association / American College of Cardiology (AHA/ACC) guidelines for the treatment of hypertension, Diovan/Valsartan is a primary agent for treatment. The patient's physician documents inefficacy to the generic formulations of valsartan and losartan (on formulary) in addition to a third angiotensin receptor blocking agent. Studies have demonstrated that a small number of individuals require use of name brand medications following use of generic formulations.(2) In this case the patient has been adequately maintained on Diovan HCT for several years and has noted intolerance to generic formulations. In conclusion, Diovan HCT is medically necessary and more effective in this case. 

The formulary drug(s) is likely to cause the patient an adverse reaction. 

The formulary drug(s) has been ineffective based on the patient's clinical history. 

The requested drug will be more effective than the formulary drug. 

The carrier's denial of a request for a Formulary Exception for Diovan HCT 160/12.5 milligrams (mg) Tablet (valsartan- hydrochlorothiazide (HCTZ)) to treat hypertension is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse

Treatment: Residential Substance Use Treatment

The insurer denied coverage for Residential Substance Use Treatment

The denial is upheld
 

This adult male was admitted to this inpatient substance residential treatment due to his excessive substance use. He reportedly was using 5-8 bags of heroin per day, $(dollar) 20 of crack 1-2 times per week, and smoking 1-2 joints of cannabis per week. He reportedly had cravings, poor insight and judgment, was homeless, unemployed, and lacked sober supports. He reportedly had psychiatric conditions as well including a diagnosis of Major Depressive Disorder and post traumatic stress disorder (PTSD). He had an extensive treatment history. He attended group and individual therapy and was taking Lithium.
 
The insurer denied coverage for continued inpatient substance residential treatment stating that it was not medically necessary treatment. They stated that he did not meet Level of Care for Alcohol and Drug Treatment (LOCADTR) criteria anymore for this residential treatment level of care. They stated that he no longer had cravings or withdrawal, medical or psychiatric concerns requiring 24-hour treatment, and they recommended a less restrictive level of care with supportive housing.
There was no specific evidence in the medical records provided for review supporting that he required inpatient substance residential treatment level of care. He had been in this intensive inpatient residential treatment for 4 months. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders states that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and or substance-free social supports to remain abstinent in an ambulatory setting. In this case it was reported that this patient required this inpatient substance residential treatment and received this care since admission but there was no reported specific evidence in the records for review to support that he still required only 24-hour residential treatment still. There were no reports of life threatening or severe withdrawal symptoms or acute medical instability that would have required 24-hour treatment and no reports of dangerous behavior or harm to self or others. There were no reports of severe psychiatric or behavioral symptoms requiring 24-hour treatment and no reports of suicidal or homicidal thoughts or behavior, psychotic symptoms, self-injurious or aggressive behavior, or inability to adequately care for her basic needs. 

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 Residential Substance Use Treatment, revenue code 1002, is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Iron Deficiency Anemia.
Treatment:  Venofer.

The health plan denied the Venofer. The health plan's determination is upheld.

This is a male with a history of iron deficiency anemia. Earlier, his Ferritin was 21 and an iron saturation was 8% (percent). His hemoglobin on was 13.5 grams/deciliter (g/dL). The patient's nadir hemoglobin in the last three months is 12.8 g/dL. He last received parenteral iron earlier this year.

Venofer was recommended; this is under review for medical necessity.

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

No. While this patient is iron deficient, his hemoglobin is within the normal range of the lab that ran the blood counts. Venofer is Food and Drug Administration (FDA) approved for the treatment of iron deficiency anemia. This patient is not anemic. An outcomes benefit for administering parenteral iron merely to replete iron stores has not been established. Finally, his iron deficit is 547 milligrams (mg) based on the Ganzoni equation. 1000 mg of Venofer was ordered, which could result in iron overload. Support for parenteral iron in this clinical scenario is not present in the peer-reviewed literature and thus, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short stature. 
Treatment: Omnitrope. 
The insurer denied Omnitrope. 
The health plan's determination is upheld. 

This is a young female diagnosed with short stature. As per the records, her bone age is 13y (years) with Tanner 4 breasts. As per visit note, she started growth hormone (GH) therapy for idiopathic short stature (ISS). No growth hormone (GH) stimulation test was provided. Under review is the use of Omnitrope. 

Omnitrope is not medically necessary for this patient. 
The patient does not meet biochemical criteria for growth hormone (GH) deficiency. Growth hormone stimulation testing is not reported. 
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means." 
The patient does not have a pretreatment height less than or equal to -2.25 standard deviation (SD). The patient therefore does not meet idiopathic short stature criteria.
The request for Omnitrope does not meet any nationally accepted criteria for use of growth hormone. Omnitrope is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin disorders
Treatment: abdominoplasty
The insurer denied an abdominoplasty.
The health plan's determination is overturned.

This patient is a male who has lost weight following bariatric surgery and suffers from excessive and redundant skin and subcutaneous tissue and Erythema Intertrigo.
This patient has had robotic sleeve gastrectomy performed and is over 12 months after weight reduction surgery at this time. He has lost over 100 pounds and has significant excess skin over the abdomen in both the horizontal and vertical directions. He continues to follow up with bariatric surgeon and a nutritionist as needed to ensure that they are maintaining their weight appropriately and following nutrition guidelines post weight reduction surgery.

Abdominoplasty is medically necessary for this patient. The records indicate that the patient has failed conservative treatment for his longstanding rashes, including treatment by with anti-fungal medication. Photos show a male with a long pannus and lower and upper abdominal folds. A panniculectomy alone will not be sufficient to treat the patient's rashes because photos show hooding of the umbilicus and two skin folds cephalad to the main pannus fold. These folds and the hooded umbilicus will be at risk for infections in only a panniculectomy is performed. In addition, the lateral hip skin folds will persist unless a vertical and horizonal abdominoplasty is performed. For this patient, abdominoplasty is required to eliminate the chronic infections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple Myeloma.
Treatment: Kyprolis/ Lenalidomide/ Dexamethasone.

The insurer denied: Kyprolis/ Lenalidomide/ Dexamethasone.  The denial is overturned.

The patient in this case is an adult male diagnosed with plasmablastic myeloma. He was treated with VD-PACE (Velcade, Dexamethasone, Cisplatin, Doxorubicin, Cyclophosphamide, Etoposide) with good response seen on positron emission tomography/computed tomography (PET/CT). Following that, he underwent autologous stem cell transplant. Maintenance therapy with Kyprolis, Revlimid, and Decadron was prescribed.

The requested Kyprolis/ Lenalidomide/ Dexamethasone is medically necessary.

This patient has plasmablastic myeloma with deletion 17p (short arm of chromosome 17. This is a high-risk myeloma. The FORTE trial was a phase 2 trial that showed use of carfilzomib and lenalidomide improved progression free survival compared to lenalidomide maintenance. National Comprehensive Cancer Network (NCCN) guidelines support use of carfilzomib and lenalidomide maintenance as a standard option for patients with high-risk myeloma. Given this randomized phase 2 data combined with National Comprehensive Cancer Network endorsement, the requested health service is medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Wegovy 0.25 mg/0.5 ml (milligrams/milliliter) pen injector. 
The insurer denied coverage for Wegovy 0.25 mg/0.5 ml pen injector. 
The denial is overturned. 
 
This is an adult female diagnosed with obesity. This request is for Wegovy. She states she has been participating in Noom: "you signed up for 12-program... your subscription shows that your auto-renew date is ...and it will be charged to your original payment". She is having difficulty losing weight. 

Her weight was 248 pounds (lbs); Body Mass Index (BMI) was 40.1. 

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 treating obesity in the form of Wegovy. The standard of care requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. The patient has a BMI of 40.1 and participates in lifestyle modifications such as diet modifications. The request meets the standard of care and is, therefore, medically necessary. 

Based on the above, the insurer's denial must be reversed. 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 prescription drug Wegovy 0.25 mg (milligrams) /0.5 ml (milliliter) pen injector is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve Treatment in the Spine (Intracept Procedure)
The insurer denied: Nerve Treatment in the Spine (Intracept 
Procedure)
The denial is upheld.

The patient is an adult male who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied as unproven. The patient has failed conservative treatment in the form of physical therapy, home exercise, epidural steroid injections, and chiropractic treatment. The patient has failed medications including non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and over the counter (OTC) analgesics. Magnetic resonance imaging (MRI) does not show Modic changes according to the attached magnetic resonance image report. Physical exam does not reveal any neurological injury.

The requested health service is not medically necessary.

The requested Intracept procedure is not medically necessary. The requested health service or procedure is not likely to be more beneficial than standard treatments. The patient is an adult male who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied as unproven. The patient has failed conservative treatment in the form of physical therapy, home exercise, epidural steroid injections, and chiropractic treatment. The patient has failed medications including non-steroidal anti-inflammatory drugs, muscle relaxants, and over the counter analgesics. Magnetic resonance imaging does not show Modic changes according to the attached magnetic resonance image report. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain and 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. In this case, as noted on the attached magnetic resonance image report, no Modic changes are reported. However, significant facet arthropathy is reported. Common treatments of axial low back pain include sacroiliac joint or facet interventions. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that alternative interventions do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient had a Left Shoulder Latarjet procedure. The patient had regional anesthesia which wore off by the morning following the procedure.  The patient took Norco, but the pain continued.  The patient returned to the hospital, where they were admitted, given intravenous (IV) acetaminophen, oral Dilaudid and Robaxin for pain. The patient was seen by the pain management team and discharged the following day. However, Klonopin and Opiates can produce sedation and respiratory depression. 

Consensus recommendations (1) regarding klonopin-opiate interactions have been made:

"Consensus recommendations for preoperative management of individual medications in each of these drug categories. While most medications should be continued perioperatively to avoid risk of relapse of the psychiatric condition, adjustments may need to be made on a case-by-case basis for certain drugs." 

In this case, the use of a strong opioid in the presence of Klonopin required close monitoring. 

This risk is again noted by Day (2):

"Benzodiazepines are used to relieve symptoms of anxiety, panic attacks, and seizures and are safe and effective when taken as prescribed and directed. However, benzodiazepines depress central nervous system (CNS) activity and, when combined with other drugs that depress CNS activity such as alcohol or opioid pain relievers, may present serious or even life-threatening problems."

The hospitalization for pain management was medically reasonable and necessary.

Based on the above, the insurer's denial must be reversed. 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 an inpatient stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Pain injections in spine

The health plan denied: Pain injections in spine
The determination is: Upheld

The patient has a chronic history of low back pain, which radiated into the right calf. The patient has been doing physical therapy and continues with a home exercise program. Medications used include meloxicam. The patient completed 2 epidural injections a few years ago, with 50 percent (%) improvement in pain and function for at least 2 months. The pain limits the patient's activities of daily living (ADL). Magnetic resonance imaging (MRI) of the lumbar spine showed multilevel degenerative disc disease, worse at lumbar spine 3-4 (L3-4) and lumbar spine 4-5 (L4-L5). The physical exam demonstrated that her gait is stable. The treating provider has planned for repeat lumbar epidural steroid injections. At issue is the medical necessity of pain injections in the spine.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of pain injections in spine is not medically necessary for this patient. The patient underwent a similar injection. Over 12 months have elapsed since the initial injection. The patient now has chronic radicular pain, for which epidural injections are not supported. It is important that epidural injections be only utilized in the proper clinical setting, such as an acute radicular exacerbation with neurologic deficits in the initial 12 months of the symptoms. The use of epidural injections in this particular scenario are not supported, as there is chronic radicular pain, which does not respond well to epidural injection. Therefore, the requested lumbar epidural steroid injection is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 Braces; D8670 Monthly Visit x 12. 

The insurer denied: D8080 Braces; D8670 Monthly Visit x 12. 
The denial is overturned. 

The patient is a teenage female. The request is for orthodontic benefits with monthly visits. She has a Class II malocclusion with upper and lower crowding and severe overjet. The health plan's prior denial of coverage was due to handicapping index scale score of 14. The denial is being appealed. 

The D8080 Braces; D8670 Monthly Visit x 12 are medically necessary. 

The patient has an anterior tooth crossbite (tooth #10 with #23) with gingival attachment loss. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem, and the monthly visits are needed to do follow ups to make sure the treatment is progressing properly. This case has medical necessity.