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

Diagnosis: Chest Pain
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) complaining of chest pain and dyspnea. Her medical history was remarkable for type 2 diabetes, hypertension, cerebral aneurysm and migraine headache.Her room air oxygen saturation was 97 percent (%). An electrocardiogram showed sinus arrhythmia with first degree atrioventricular (AV) block. There were no acute changes. Her serum troponin level was normal and remained normal when re-measured. The patient was treated with aspirin and was admitted to the hospital. An echocardiogram was performed and was normal. Myocardial perfusion imaging showed no evidence of ischemia. She was discharged. The medical necessity for an inpatient admission is at issue.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Thermal Destruction of Intraosseous Basivertebral Nerve
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve 
The health plan's determination is upheld. 

The patient is a male who is diagnosed with Vertebrogenic Low Back Pain; Chronic Midline Low Back Pain without Sciatica. According to the records provided, the patient was recommended to undergo the Intracept procedure (interosseous basivertebral nerve ablation).

Intraosseous Basivertebral Nerve Ablation 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 is noted to have a history of chronic back pain that has not responded to conventional conservative treatment and injections. The provider feels that the patient's pain is coming from Modic changes at L5 and S1, and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish its safety and efficacy. This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Thermal Destruction of Intraosseous Basivertebral Nerve
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve 
The health plan's determination is upheld. 

The patient is a male with complaints of chronic low back pain. Prior treatments have included activity modification, lumbar injections, therapy, as well as medications. Pain severely impacts activities of daily living (ADL). Pain ranges from 6-10 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type II changes at disc spaces L (lumbar) 5 and S (sacral) 1. 

The proposed Thermal Destruction of Intraosseous Basivertebral Nerve 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. 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 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 Thermal Destruction of Intraosseous Basivertebral Nerve 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: back pain
Treatment: Thermal Destruction of Intraosseous Basivertebral Nerve
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve 
The health plan's determination is overturned. 

This is a male who has midline lumbosacral spine pain for multiple years. His pain is worse with sitting, forward bending and going from sitting to standing position. Standing and walking help to alleviate his pain. His prior treatments include physical therapy (PT), pain medications, lumbar epidural injections, and radiofrequency ablation, but none of these provided adequate relief for his back pain. Physical exam (PE) was unremarkable. Lumbar magnetic resonance imaging (MRI) images showed severe Modic type 2 changes at L (lumbar)5/S (sacral)1.

Thermal Destruction of Intraosseous Basivertebral Nerve is 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 basivertebral nerves. There are multiple clinical trials demonstrated the sustained improvements in pain and function from this intervention for patients with vertebrogenic pain. This patient had failed extensive treatments including physical therapy (PT), pain medications, lumbar epidural injections, and radiofrequency ablation. His symptoms are consistent with vertebrogenic pain. Further interventions are medically necessary to improve his pain and function. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the Intracept procedure is likely to be more beneficial than any standard treatments for the insured's disabling condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection (UTI) status cystoscopy and kidney stone removal.
Treatment: Inpatient admission 
The insurer denied coverage for Inpatient admission.
The denial is Upheld.

The patient was admitted for abdominal pain and dysuria. A urinalysis showed signs of possible infection and was started on intravenous (IV) fluid and antibiotics. The patient was evaluated by Urology for left kidney stone on renal ultrasound (US). The patient underwent cystoscopy and kidney stone was removed. The patient tolerated the procedure well and was discharged in stable condition.

The patient was admitted for urinary tract infection (UTI), the patient's condition responded to standard therapy in 48 hours. The patient remained hemodynamically stable without complications and was discharged in stable condition.

Per evidence-based literature, the observation level of care is appropriate to treat this patient's condition. A multiyear database analysis including a nationally weighted sample of over 1.9 million pediatric patients presenting to an Emergency Department (ED) with a UTI found an admission rate of 25% (percent) for infants younger than 1 year, 3% (percent) for patients 1 to 5 years of age, 2% (percent) for patients 6 to 13 years of age, and 12% (percent) for those 14 to 17 years of age [1].

A multicenter study including 350 children presenting to an ED with a first febrile UTI found that 25% (percent) were admitted for inpatient care [2]. This patient was admitted for UTI and was treated with IV antibiotics and fluid. The patient's condition responded appropriately within 48 hours.

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

Diagnosis: Pyoderma gangrenosum, polycystic ovarian syndrome (PCOS), prediabetes, and metabolic syndrome
Treatment: Victoza
The insurer denied: Victoza
The denial is upheld.

This patient is an adult female with diagnoses of pyoderma gangrenosum, polycystic ovarian syndrome (PCOS), prediabetes, and metabolic syndrome. The request is for Victoza (liraglutide) for treatment of PCOS (polycystic ovarian syndrome), prediabetes, and metabolic syndrome.

The requested Victoza is not medically necessary.

All the relevant medical information available was reviewed.
Victoza is approved for the treatment of type II diabetes mellitus. Victoza is currently not United States Food and Drug Administration (FDA)-approved for the treatment of PCOS (polycystic ovarian syndrome), pre-diabetes, or obesity.
The patient's current medical diagnoses are not included in the indications for Victoza. Victoza is also not FDA (United States Food and Drug Administration)-approved for patient's medical diagnoses and not indicated in the compendia of current literature guidelines. Therefore, the requested Victoza is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Falls. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns for syncope and collapse. Pertinent history included recent fall with right distal ulnar fracture, recurrent falls in the setting of ongoing alcohol abuse, alcohol-induced decompensated liver cirrhosis, and hypertension. 

The inpatient hospital admission was not medically necessary. The patient had a history of recurrent falls in the setting of alcohol abuse including a recent ulnar fracture who presented with syncope and a fall. Initial examination documented the patient as alert, oriented, hemodynamically stable, and without focal neurologic deficits. Initial evaluation revealed hypokalemia, hypomagnesemia, and re-visualization of the ulnar fracture. Electrocardiogram was unremarkable. Echocardiogram was unremarkable. Electrolyte replacement was provided. Orthopedic surgery re-placed the splint and electrophysiology ruled out a cardiac etiology. No recurrence of syncope was noted during the hospital stay. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain

Treatment: Hyaluronan Injections for joint problem (Procedure Code J7327)

The insurer denied coverage for Hyaluronan Injections for joint problem (Procedure Code J7327)

The denial is upheld 


This is an adult female with right knee pain. She reported recent onset of anterior knee pain after skiing. The physical examination showed tenderness to the patella. There was pain at the extreme of motion. The physician provided an injection of Monovisc (hyaluronin). 

The indications for use of viscosupplementation have been for the management of osteoarthritis to the knee which has not responded to pharmacological and non-pharmacological treatment. There must be a confirmed diagnosis of osteoarthritis. The records show anterior knee pain of short duration secondary to skiing. This is not a symptom of arthritis. There were no clinical findings for arthritis. There were no imaging studies showing arthritis. Based upon clinical presentation alone, the injection would not be necessary. 

The records also show no conservative treatments were provided prior to the administration of viscosupplementation. In conclusion, there is no indication for the medication as provided. 

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 Hyaluronan Injections for joint problem (Procedure Code J7327) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status (AMS)
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
This is an adult with past medical history significant for arthritis, prediabetes, urinary tract infection and overactive bladder who presented to the emergency department (ED) with complaints of altered mental status (AMS).

Vital signs on presentation included: Temperature -99.8 Fahrenheit, Blood Pressure -146/76, Pulse - 120, Respiratory Rate - 16, oxygen (O2) saturation -99%. Laboratory results included the following: white blood cell count (WBC) - 5.1k, hemoglobin (Hgb) - 11.8, hematocrit (Hct) - 39.4, creatinine - 0.9, glucose - 110.

The patient was started on intravenous (IV) fluids and empiric antibiotics (Vancomycin and Zosyn) for possible urinary tract infection (UTI). Head computed tomography (CT) scan showed no acute intracranial hemorrhage or infarct. Chest radiographic image (CXR) was normal. The patient remained afebrile and hemodynamically stable with improvement in mental status. The patient was discharged to continue outpatient management.

According to documentation, the patient was admitted for change in mental status. Otherwise, patient was afebrile, hemodynamically stable with unremarkable laboratory findings including normal WBC. All imaging studies were negative, the patient had no evidence of a disseminated infection. Based on above findings, the 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 inpatient admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative (chronic) proctitis with unsp complications
Treatment: Budesonide ER 9MG OR TB24
The insurer denied Budesonide ER 9MG OR TB24
The determination is upheld.

This is a female patient with ulcerative colitis.  She has had diarrhea, blood in the stool, and dyschezia; she had temporary relief with prednisone.  She has failed Humira, had a "robust response" to 5-aminosalicylate therapy but did not adhere (there are paid claims for mesalamine 400 milligrams (mg) delayed release (DR) and mesalamine 4 grams (gm) enema), and Stelara use is planned.  Budesonide extended release (ER) 9 milligrams (mg) daily for the treatment of ulcerative colitis.  The request for the non-formulary drug was not approved as the formulary drugs sulfasasalazine 400 mg tablets, sulfasasalazine 500 mg delayed release tablets, dipentum capsules, bensalazide capsules, mesalamine 4 gram enemas (Generic Rowasa), mesalamine 800 mg delayed release tablets (generic Asacol HD), mesalamine 1.2 gm enteric coated tables (generic Lialda),mesalamine 1000 mg suppositories (generic Canasa), and mesalamine 400 mg delayed release capsules (generic Delzicol) have not been attempted and failed.  At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The request for budesonide over the formulary alternatives is not supported based on the submitted information.  American Gastroenterological Association guidelines for the management of mild to moderate Ulcerative Colitis state "In patients with mild-moderate Ulcerative Colitis, the American Gastroenterological Association (AGA) suggests using standard-dose oral mesalamine or diazo-bonded 5-ASA, (aminosalicylates) rather than budesonide MMX (multi-matrix)or controlled ileal release budesonide for induction of remission" [1].  American Gastroenterological Association guidelines for the management of moderate to severe ulcerative colitis do not recommend the use of budesonide [2].  American College of Gastroenterology guidelines for the treatment of ulcerative colitis do not recommend budesonide in patients with mild left-sided ulcerative colitis who have not attempted oral and rectal 5-aminosalicylate therapy at appropriate doses, or mild to moderate ulcerative colitis who have not attempted oral 5-aminosalicylates [3].  Although limited, comparisons of salicylate therapies such as the formulary alternatives with budesonide do not support budesonide as safer and more effective [4-6].  In this case, the patient has attempted 5-aminosalicylate medications with a "robust response", and there is no documented attempt and failure of 5-aminosalicylate therapy, including the formulary alternatives, to support the use of budesonide.  For these reasons, the request is not supported based on the submitted information.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Braces. 
The insurer denied Braces. 
The determination is overturned. 

The patient is a male with a Class I malocclusion, severe crowding, and an anterior crossbite of number (#) 10. He is treatment planned for 36 months of orthodontics with extraction of four first premolars to correct his malocclusion. At issue is the medical necessity of braces. 

This patient presents with an anterior crossbite and severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) These problems are much more time consuming to correct than the patient's current orthodontic problem. 
The patient has severe maxillary and mandibular crowding with #10 in crossbite. This tooth has a high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons. orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I Occlusion
Treatment: braces
The insurer denied braces.
The health plan's determination is overturned. 

The patient in question is a female presenting with a skeletal Class I malocclusion and minor crowding. She has a 1 millimeter (mm) anterior open bite. Tooth 14 is decayed to the point there are only root tips left. She is treatment planned for Braces. 

Braces are medically necessary. The patient has an anterior open bite. Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite.
Orthodontic treatment is medically necessary for this patient due to the side effect described above, and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: crossbite
Treatment: Braces/monthly visits
The insurer denied braces/monthly visits
The health plan's determination is overturned.

The patient in question is a young male. He is class III, with a posterior crossbite on the right. Tooth number 7 (#7) is in crossbite. He has a functional shift to the right. He is treatment planned for orthodontics including rapid palatal expansion (RPE) to correct his crossbites and crowding.

Braces and 12 Monthly Visits are medically necessary for this patient.
This patient presents with crowding and tooth #7 in crossbite. Most significant is the posterior crossbite and corresponding mandibular midline shift to the right. There is strong medical evidence that that early correction of posterior crossbites with a shift reduces the need for future treatment. The evidence shows if such a crossbite is not corrected before the patient reaches skeletal maturity, the ability to achieve orthopedic expansion is greatly reduced. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain. 
Treatment: pain management Injection in Spine (Outpatient Services 62323 x 1). 
The insurer denied the pain management injection in spine (Outpatient Services 62323 x 1). 
The health plan's determination is overturned. 

The patient is a female how has low back pain with radicular pain going down her both legs. She had previously undergone 10 sessions of physical therapy. Unfortunately, her leg pain appears to be worsening. She had also tried ibuprofen and Tylenol with no improvement. The intensity of her pain ranges from 3/10 to 8/10. Physical examination was positive for straight leg raise test, worse on the right. Magnetic resonance imaging (MRI) showed broad-based posterior disc protrusion at L (lumbar)5-S (sacral)1 level. 

Pain Management Injection in Spine (Outpatient Services 62323 x 1) is medically necessary for this patient. 
This patient has lower back pain with radicular symptoms in the lower extremities consistent with her MRI finding of the disc bulge at L5-S1 level. She had failed conservative treatments including physical therapy and pain medications.  Her pain is severe enough with limitations on her activities of daily living. Further treatments are medically necessary to improve her pain and function. The next step treatment is an epidural steroid injection at L5-S1 level. The alternative is lumbar laminectomy discectomy surgery which carries significantly more risks than the epidural steroid injection.